TITLE 40.SOCIAL SERVICES AND ASSISTANCE

Part 1. TEXAS DEPARTMENT OF HUMAN SERVICES

Chapter 19. NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION

Subchapter X. REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES

40 TAC §19.2322

The Texas Department of Human Services (DHS) proposes to amend §19.2322, concerning allocation, reallocation, and decertification requirements, in its Nursing Facility Requirements for Licensure and Medicaid Certification chapter. The amendment reduces the documentation regarding quality of care issues that must be provided to DHS when applying for a special commissioner's waiver of restrictions on contracting for Medicaid beds in a nursing facility. The amendment reduces the requirements necessary for a waiver for facilities to meet the needs of underserved minorities. The amendment also makes it easier for a facility to obtain a Medicaid bed for a Medicaid resident when no Medicaid bed is available.

Eric M. Bost, commissioner, has determined that for the first five- year period the proposed section will be in effect there will be no fiscal implications for state or local governments as a result of enforcing or administering the section.

Mr. Bost also has determined that for each year of the first five years the section is in effect the public benefit anticipated as a result of adoption of the proposed rule will be the elimination of counter-productive restrictions on nursing facility bed allocations. There will be no effect on small or micro businesses as a result of enforcing or administering the section, because the changes simply remove several unnecessary restrictions on Medicaid bed allocations in nursing facilities. There is no anticipated economic cost to persons who are required to comply with the proposed section.

Questions about the content of this proposal may be directed to Connie Pate at 438-3529 in DHS's Long Term Care-Policy Section. Written comments on the proposal may be submitted to Supervisor, Rules and Handbooks Unit-079, Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030, within 30 days of publication in the Texas Register .

Under §2007.003(b) of the Texas Government Code, the department has determined that Chapter 2007 of the Government Code does not apply to these rules. Accordingly, the department is not required to complete a takings impact assessment regarding these rules.

The amendment is proposed under the Human Resources Code, Title 2, Chapters 22 and 32, which authorizes the department to administer public and medical assistance programs and under Texas Government Code §531.021, which provides the Health and Human Services Commission with the authority to administer federal medical assistance funds.

The amendment implements the Human Resources Code, §§22.001- 22.030 and §§32.001-32.042.

§19.2322.Allocation, Reallocation, and Decertification Requirements.

(a)-(d)

(No change.)

(e)

Exemptions. If the NFO meets all criteria, DHS may grant the following exemptions from the policy stated in subsection (c) of this section.

(1)-(5)

(No change.)

(6)

Special commissioner's waiver.

(A)

The commissioner of DHS has authority to waive the restriction on contracting in subsection (c) of this section and direct DHS to enter into Medicaid contracts with NFOs that satisfy the requirements specified in this subparagraph. In a manner acceptable to DHS, each of these NFOs must:

(i)

(No change.)

[ (ii)

document that there are problems with the quality of care available in the NFO's community, and show that new Medicaid beds will remedy these problems;]

(ii)

[ (iii) ] demonstrate that Medicaid residents in their community do not have reasonable access to quality nursing facility care;

(iii)

[ (iv) ] document strong community support for a new Medicaid nursing facility; and

(iv)

[ (v) ] demonstrate a history of quality care, as specified in subsection (d) of this section. An applicant that has not owned or operated a nursing facility may apply; however, DHS will evaluate the applicant and any controlling person to determine if the applicant has the capacity to provide quality care.

(B)

(No change.)

(7)

Criminal justice and underserved minorities. The commissioner may grant a waiver of these restrictions for a contract if the commissioner determines that beds are necessary for the following circumstances:

(A)

(No change.)

(B)

to meet the documented demand in underserved minority communities where beds are not available from existing resources. For purposes of this waiver, the term minority [ shall mean ] means all persons who are African-American [ black ], Hispanic [ hispanic ], Asian or Pacific islander, American Indian, or Alaskan native. The facility must:

[ (i)

be located in a county with a total population of at least 1,000,000, according to the most recent U.S. census;]

(i)

[ (ii) ] serve a zip code whose minority population is greater than 50%, according to the most recent U.S. census; and

(ii)

[ (iii) ] document that minority residents in the zip code in which the facility is located are unable to attain Medicaid long term care services in that specific location, due to lack of such service availability . [ ; and ]

[ (iv)

be the only waived facility, as defined in this paragraph, in that county.]

(C)-(D)

(No change.)

(8)

(No change.)

(9)

Medicaid eligible residents for whom no Medicaid bed is available. Facilities may obtain certified beds to serve residents by meeting the following criteria:

(A)

(No change.)

(B)

The NFO must:

(i)

(No change.)

(ii)

meet requirements for Medicaid participation; and

(iii)

obtain a Medicaid contract . [ ; and ]

[ (iv)

have demonstrated to DHS a satisfactory history of quality of care as specified in subsection (d) of this section.]

(C)-(D)

(No change.)

(f)-(j)

(No change.)

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 11, 2001.

TRD-200102090

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


Chapter 97. LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES

The Texas Department of Human Services (DHS) proposes amendments to §§97.1-97.3 (Subchapter A, General Provisions), §97.11, §§97.13-97.16 (Subchapter B, Application and Issuance of a License); the repeal of §§97.21-97.28 (Subchapter C, Service Standards), §§97.51-97.54 (Subchapter D, Enforcement), §§97.61-97.62 (Subchapter E, Home Health Aides and Medication Aides), and §§97.71-97.72 (Subchapter F, Advisory Committees); and proposes new §97.201 (new Subchapter C, Minimum Standards for All Home and Community Support Services Agencies (HCSSAs), General Provisions), §§97.211-97.222 (new Subchapter C, Minimum Standards for All HCSSAs, Conditions of a License), §§97.241-97.257 (new Subchapter C, Minimum Standards for All HCSSAs, Agency Administration), §§97.281-97.303 (new Subchapter C, Minimum Standards for All HCSSAs, Provision and Coordination of Treatment and Services), and §§97.321-97.322 (new Subchapter C, Minimum Standards for All HCSSAs, Branch Offices and Alternate Delivery Sites), §§97.401-97.407 (new Subchapter D, Additional Standards Specific to License Category and Specific to Special Services), §§97.501-97.502 (new Subchapter E, Surveys), §§97.601-97.604 (new Subchapter F, Enforcement), and §97.701 (new Subchapter G, Home Health Aides), in its Licensing Standards for Home and Community Support Services Agencies chapter. The phrase "Licensing Standards for" is being added to the chapter title to identify the rules as licensing rules.

DHS has been reviewing Chapter 97 since the HCSSA program was transferred to this agency in September 1999 in order to reorganize the rule base, clarify ambiguous wording, eliminate duplication, strengthen the licensure standards where needed and to reformat the end product to make it more consumer friendly. This rule package is the second part of a three-part review of Chapter 97. The second part of the review concentrated on Subchapter C, Service Standards.

To accommodate the reorganization of Subchapter C and to allow for the future expansion of Subchapter B, all of existing Subchapters C - F are being repealed and proposed as new rules under Chapter 97, Subchapters C - G, with the exception of §97.62, §97.71, and 97.72. Section 97.62, concerning home health medication aides, is being repealed and has been proposed as 40 TAC §95.128 in the March 30, 2001, issue of the Texas Register . Section 97.71, concerning the HCSSA Advisory Council, and §97.72, concerning the DHS/Board of Nurse Examiners Memorandum of Understanding Advisory Committee, are being repealed and have been proposed as new 40 TAC §79.403(f) and (g) in the April 13, 2001, issue of the Texas Register .

New Subchapter C contains the minimum standards that are applicable to all HCSSAs.

New Subchapter D contains additional standards that are specific to license category and specific to special services that an agency may provide. The license categories covered under Subchapter D include licensed home health services, licensed and certified home health services, hospice services, personal assistance services, home dialysis services, psychoactive services, and home intravenous therapy.

New Subchapters E and G contain the procedures for survey and complaint investigation and enforcement, and requirements for home health aides. Existing §97.54, concerning criminal history checks for unlicensed personnel was inappropriately located in the rule base under enforcement and is being repealed and proposed as new §97.247 under agency responsibilities in new Subchapter C. These subchapters and the criminal history check procedures have not yet been subject to a review to reorganize the rule base, clarify ambiguous wording, eliminate duplication and to reformat the end product to make it more consumer friendly; however, certain revisions were made to address concerns in the rules in need of immediate attention. These revisions are described in the summary of rule changes further on in this preamble.

New Subchapters E and G, as well as rule language covering the HCSSA Advisory Council, the DHS/Board of Nurse Examiners MOU Advisory Committee, and criminal history check procedures will undergo a complete review by DHS during the third and final part of the a three part schedule for review of Chapter 97 rules.

A summary of the major rule changes included in this proposal is as follows.

New definitions are added and existing definitions are amended for clarification, to remove regulatory language, and to comply with statutory changes.

Under conditions of a license, language is added to require an agency to post notice of any changes in the agency license so the public is made aware of any changes in an agency's license. Language that required DHS's approval prior to an agency transfer is being deleted, because it was determined to exceed statutory authority. An agency must still provide notification to DHS 30 calendar days before the intended relocation. Notification requirements for certain agency changes are being amended to provide notification to DHS before the changes rather than after the changes occur. Language is also proposed to require criminal history checks for a new administrator and a new chief financial officer. Additionally, language is proposed to require an agency to provide written notice 30 days prior to the expansion of its service area, instead of 30 days after the effective date of the expansion. This includes parent agencies, branch offices, and administrative support sites. This will allow DHS time to review compliance history. An exemption is proposed for emergencies that will be determined by DHS.

New requirements are proposed for policies governing client conduct and responsibility and client rights applicable to all agencies, peer review to ensure that all professional disciplines comply with their respective professional practice act, and drug testing of an agency's employees if testing is performed by an agency. A new policy requirement is added to ensure that clients are educated in how to access care from another health care provider after regular business hours. Another new policy requirement is proposed that requires an agency to ensure that all employees are fully informed and understand all of the agency's policies.

Statutory language specific to advance directives policy requirements is added. Current rules just reference the statutory language. Minimum standards for infection control are established. Existing language just requires a policy for infection control.

Minimum standards are established for a Quality Assurance (QA) Program, QA committee membership, and frequency of QA committee meetings. Existing rules were determined to be too vague.

New language is proposed and existing language is amended to require that the steps taken to coordinate services be documented in the client record, to clarify existing client record requirements, and to establish a time limit of 14 days for incorporating clinical and progress notes into the clinical record. Current rules do not specify a time limit.

New language is added to strengthen the use of volunteers.

Two new agency disclosure requirements are proposed for reporting of abuse, neglect, or exploitation of a client, and for an agreement to and acknowledgement of services by home health medication aides.

New language is proposed to require that lists of clients be maintained for each category of service licensed and specific information be included on the list. This will enable DHS surveyors to survey an agency based on category of service provided.

Language is proposed to allow physician orders to be received via facsimile and to require an agency to adopt a policy for protocols to follow when accepting physician orders via facsimile.

Management and ownership responsibilities are added in accordance with statutory requirements. The rules will make the licensee more accountable for the operations of the agency. New language requires that an agency have a written organization structure in a chart or narrative format. The language clarifies DHS's expectations for the written organization structure. New language also requires the licensee to appoint the administrator as well as an alternate to act in the administrator's absence. Existing rules assign responsibility for the appointment of an alternate to the administrator.

The following additional job responsibilities are proposed for the administrator: to ensure adequate staff education and evaluations, and to supervise and evaluate client satisfaction survey reports. Health and Safety Code, §142.0011, added in 1999, requires the rules to address client satisfaction. Additional qualifications for the administrator, including the alternate or other designee, are added. An administrator who qualifies under the training and experience qualification must also have a high school diploma or a GED. This is also added to the qualifications for the administrator of an agency licensed to deliver personal assistance services only. Continuing education (CE) requirements are added as a condition of employment for the administrator. The administrator must have documented completion of a minimum of six clock hours per year at a health service administration seminar.

New language is added to allow the supervising nurse to be available in person or via telecommunication, so that the supervising nurse could be located at all times. An amendment to the qualification that requires the supervising nurse to "be a registered nurse (RN)" clarifies that the registered nurse must to be "licensed in the state of Texas or in accordance with the Board of Nurse Examiners rules for Nurse Licensure Compact (NLC)."

An amendment to the qualification that establishes the experience requirements for the supervising nurse requires at least two years of current experience as a registered nurse in a health care setting that provides care for children, adults, or geriatric clients. For experience to be considered current, it must have been obtained within three years prior to assuming the role of supervising nurse. One year of experience working as a consultant or in some other capacity that entailed administering home health care standards may be substituted for one year of the required nursing experience. DHS is concerned that many agencies were filling these positions with individuals without any real experience in the area of a home or health care setting that provides for children, adults, or geriatric clients. There is real concern that individuals may be reentering the nursing field after a period of time and are not current on the latest information or best practices. This area is changing so rapidly that it is important that professionals, who are acting in the role of a supervising nurse and are directing other staff, be well-informed and knowledgeable about the most recent medical and social advances. DHS believes that increasing the experience requirements for the supervising nurse will help ensure higher quality of care and service. DHS also believes that many of the current quality of care and service concerns that are occurring at agencies will decrease by requiring a more experienced supervising nurse.

Under standards specific to licensed home health agencies, the following changes are proposed. Language relating to the qualifications for the social worker when performing medical social services is added. The qualifications are inappropriately located in the definitions section in current rules. A requirement is added that unlicensed personnel utilized by an agency to provide home health services be required to demonstrate competency in the task assigned when competency cannot be determined through education, license or certification, or experience.

Under standards specific to agencies licensed to provide hospice services, the following changes are proposed. The term "drug profile" is changed to "medication list" and the definition of "medication list" is modified to reflect the change in the definition section. An agency must keep a medication list, and a pharmacy keeps a drug profile. Language is added to require the hospice physician or registered nurse to contact the client within 24 hours prior to the start of care to determine the immediate care and support needs of the client. Language that prohibited a hospice from discontinuing care provided to or discharging a client because of the client's inability to pay for that care is being removed because the rule was determined to exceed DHS's authority to impose as a licensing standard. In addition, the administrative penalty for violation of that rule is being removed as well. Some of the language relating to volunteers and client rights is moved to Subchapter C to apply to all licensed categories of agencies.

Under standards specific to agencies licensed to provide personal assistance services (PAS), the following changes are proposed. Requirements are added for including the "planned date of service initiation" in the individualized service plan. Gastrostomy tube (g- tube) feedings or medication administration are no longer limited to short-term respite care. The proposal also clarifies language relating to the qualified trainer of a training and competency program for the performance of g-tube feedings.

Under standards specific to agencies licensed to provide home dialysis services, the following changes are proposed. Client rights specific to home dialysis are moved to Subchapter C and made applicable to all agencies. Requirements are added for having emergency drugs available as specified by the medical director. Standards for performing home dialysis are updated to reflect current standards.

Under DHS's survey procedures, language is added to state that immediate enforcement action will be taken for failure to grant access to all books, records, or other documents maintained by or on behalf of the agency to the extent necessary to ensure compliance with the statute, rules, an order of the commissioner, a court order granting injunctive relief, or other enforcement action. Additionally, the proposal clarifies that, if Medicare certification for a licensed and certified agency is denied by the Health Care Financing Administration (HCFA) or the agency withdraws from the Medicare program, the agency may only operate under the category remaining on the current license.

Under DHS's procedures for license denial, suspension, or revocation, if DHS takes enforcement action against an agency, its owner(s), or its affiliate(s), the agency may not apply for an agency license "or make any requests to change categories of license for one year" following the effective date of the enforcement action. The language "or make any requests to change categories of a license for one year" is new language. DHS has had agencies that are licensed with the categories of "licensed and certified" and "personal assistant services," when their licensed and certified (Medicare) category is terminated for poor quality of care and they want to add the category of licensed home health services. A year's wait would allow the home health agency to regroup and educate the staff to provide skilled services.

The schedules of administrative penalties are amended to reflect the reorganization of the new rules. In instances where a rule previously applied only to one category of license but now applies to all categories of licenses and where there was a penalty already established for violation of that rule, the penalty will be applied to all categories of licenses for failure to comply. The schedule of penalties are more streamlined to reflect the elimination of duplication and the reorganization of the rule base.

Additional minor changes are made throughout the rules for the purpose of updating and clarifying language.

Eric M. Bost, commissioner, has determined that for the first five- year period the sections are in effect there will be no fiscal implications for state or local government as a result of enforcing or administering the sections.

Mr. Bost also has determined that for each year of the first five years the section are in effect the public benefit anticipated as a result of adoption of the proposed rule will be more consumer-friendly rules that have been streamlined by clarifying ambiguous wording, eliminating duplication, strengthening the licensure process, and reformatting. As a result of the new requirements for six clock hours of continuing education, there may be an increase in economic cost to persons who are administrators of home and community support services agencies and are required to comply with the proposed sections. It is difficult to determine if there will be an increase in cost, because some continuing education is provided at no cost. Also, if an administrator presently receives at least six clock hours of the required continuing education per year, there will be no additional cost to the individual. Some HCSSAs may opt to pay for the continuing education if there is a cost. The estimated cost to individuals, small businesses, microbusinesses, or large businesses will depend on who pays and is estimated to be under $500 annually.

Questions about the content of this proposal may be directed to Linda Kotek at (512) 438-3158 in DHS's Long Term Care Section. Written comments on the proposal may be submitted to Supervisor, Rules and Handbooks Unit-049, Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030, within 30 days of publication in the Texas Register .

Under §2007.003(b) of the Texas Government Code, the department has determined that Chapter 2007 of the Government Code does not apply to these rules. Accordingly, the department is not required to complete a takings impact assessment regarding these rules.

Subchapter A. GENERAL PROVISIONS

40 TAC §§97.1 - 97.3

The amendments are proposed under the Health and Safety Code, Chapter 142, which provides the department with the authority to adopt rules for the licensing and regulation of home and community support services agencies.

The amendments implement the Health and Safety Code, Chapter 142.001-142.030.

§97.1.Purpose and Scope .

(a)

Purpose.

(1)

The purpose of this chapter [ these sections ] is to implement the Health and Safety Code, Chapter 142, which provides the Texas Department of Human Services (DHS) with the authority to adopt minimum standards that a person must meet in order to be licensed as a home and community support services agency (HCSSA) and also to qualify to provide certified home health services. The requirements serve as a basis for survey activities for licensure [ requires a home and community support services agency to be licensed by the Texas Department of Human Services ].

(2)

Except as provided by the Health and Safety Code, §142.003 (relating to Exemptions from Licensing Requirement), a person, including a health care facility licensed under the Health and Safety Code, Chapter 142, may not engage in the business of providing home health, hospice, or personal assistance services, or represent to the public that the person is a provider of home health, hospice, or personal assistance services for pay without a HCSSA license authorizing the person to perform those services issued by DHS for each place of business from which home health, hospice, or personal assistance services are directed. A certified HCSSA must have a license to provide certified home health services.

(b)

Scope. This chapter establishes the minimum standards for acceptable quality of care, and a violation of a minimum standard is a violation of law. These minimum standards are adopted to protect clients of HCSSAs by ensuring that the clients receive quality care, enhancing their quality of life.

[ (b)

These sections provide minimum standards for acceptable quality of care, which include the following components:]

[ (1)

client independence and self-determination;]

[ (2)

humane treatment;]

[ (3)

continuity of care;]

[ (4)

coordination of services;]

[ (5)

professionalism of service providers;]

[ (6)

quality of life; and]

[ (7)

client satisfaction with services.]

(c)

Limitations. Requirements established by private or public funding sources [ (e.g. ], such as health maintenance organizations or other private third-party insurance, Medicaid (Title XIX of the Social Security Act), Medicare (Title XVIII of the Social Security Act), or state-sponsored funding programs [ ) ] are separate and apart from the requirements in this chapter for agencies. No matter what funding sources or requirements apply to an agency, the agency must still comply with the applicable provisions in the statute and this chapter. The agency is responsible for researching availability of any funding source to cover the service(s) the agency provides.

§97.2.Definitions.

The following words and terms, when used in these sections, shall have the following meanings, unless the context clearly indicates otherwise.

(1)-(4)

(No change.)

(5)

Advanced practice nurse--A registered nurse who is approved by the Board of Nurse Examiners (BNE) [ for the State of Texas ] to practice as an advanced practice nurse and who maintains compliance with the applicable rules of the BNE. See BNE's definition of advanced practice nurse in 22 TAC §221.1 (concerning definitions) [ on the basis of completion of an advanced educational program. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist ].

(6)-(7)

(No change.)

(8)

Alternate delivery site--A facility or site, including a residential unit or an inpatient unit:

(A)

(No change.)

(B)

that is not the hospice's principal place of business . For the purposes of this definition the hospice's principal place of business is the parent office for the hospice ;

(C)-(D)

(No change.)

(9)

(No change.)

(10)

Assistance with medication [ or treatment regimen ]--Any needed ancillary aid provided to a client in the client's self-administered medication or treatment regimen, such as reminding a client to take a medication at the prescribed time, opening and closing a medication container, pouring a predetermined quantity of liquid to be ingested, returning a medication to the proper storage area, and assisting in reordering medications from a pharmacy. Such ancillary aid does [ must ] not include administration of any medication, unless the client has the cognitive ability to direct the administration of their medication and would self-administer if not for a functional limitation.

(11)-(21)

(No change.)

(22)

Complaint--An allegation against an agency regulated by or against an employee of an agency regulated by the Texas Department of Human Services (DHS). The complaint may be general or specific and can involve staff, clients, volunteers, care issues, and administration.

(23)

[ (22) ] Controlling person--A person with the ability, acting alone or in concert with others, to directly or indirectly, influence, direct, or cause the direction of the management, expenditure of money, or policies of an agency or other person.

(A)

A controlling person includes:

(i)

a management company, landlord, or other business entity that operates or contracts with others for the operation of an agency;

(ii)

any person who is a controlling person of a management company or other business entity that operates an agency or that contracts with another person for the operation of an agency;

(iii)

any other individual who, because of a personal, familial, or other relationship with the owner, manager, landlord, tenant, or provider of an agency, is in a position of actual control or authority with respect to the agency, without regard to whether the individual is formally named as an owner, manager, director, officer, provider, consultant, contractor, or employee of the agency.

(B)

A controlling person, as described by subparagraph (A)(iii) of this paragraph, does not include an employee, lender, secured creditor, or landlord, or other person who does not exercise formal or actual influence or control over the operation of an agency.

(24)

[ (23) ] Counselor--An individual qualified under Medicare standards to provide counseling services, including bereavement, dietary, spiritual, and other counseling services to both the client and the family.

(25)

[ (24) ] DHS [ Department ]--The Texas Department of Human Services [ (DHS) ].

(26)

[ (25) ] Dialysis treatment record--For home dialysis designation, a dated and signed written notation by the person providing dialysis treatment which contains a description of signs and symptoms, machine parameters and pressure settings, type of dialyzer and dialysate, actual pre- and post-treatment weight, medications administered as part of the treatment, and the client's response to treatment.

(27)

[ (26) ] Dietitian--A person who is currently licensed under the laws of the State of Texas [ this state ] to use the title of licensed dietitian or provisional licensed dietitian, or who is a registered dietitian.

(28)

[ (27) ] Director--The director of the Home and Community Support Services Agencies Program of the Texas Department of Human Services or his or her designee.

(29)

[ (28) ] End stage renal disease (ESRD)--For home dialysis designation, the stage of renal impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplantation to maintain life.

(30)

[ (29) ] Freestanding hospice--An agency that provides hospice services to clients of the agency who are residing at the agency's physical location including inpatient and respite care.

(31)

[ (30) ] Functional need--Needs of the individual which require services without regard to diagnosis or label.

(32)

[ (31) ] Health assessment--A determination of a client's physical and mental status through inventory of systems.

(33)

[ (32) ] Home and community support services agency--A person who provides home health, hospice, or personal assistance services for pay or other consideration in a client's residence, an independent living environment, or another appropriate location.

(34)

[ (33) ] Home health medication aide--A person permitted under the Health and Safety Code, Chapter 142, Subchapter B.

(35)

[ (34) ] Home health service--The provision of one or more of the following health services required by an individual in a residence or independent living environment:

(A)

nursing , including blood pressure monitoring and diabetes treatment ;

(B)

physical, occupational, speech, or respiratory therapy;

(C)

medical social service;

(D)

intravenous therapy;

(E)

dialysis;

(F)

service provided by unlicensed personnel under the delegation of a licensed health professional;

(G)

the furnishing of medical equipment and supplies, excluding drugs and medicines; or

(H)

nutritional counseling.

(36)

[ (35) ] Hospice--A person licensed under this chapter to provide hospice services, including a person who owns or operates a residential unit or an inpatient unit.

(37)

[ (36) ] Hospice services--Services, including services provided by unlicensed personnel under the delegation of a registered nurse or physical therapist, provided to a client or a client's family as part of a coordinated program consistent with the standards and rules adopted under this chapter. These services include palliative care for terminally ill clients and support services for clients and their families that:

(A)

are available 24 hours a day, seven days a week, during the last stages of illness, during death, and during bereavement;

(B)

are provided by a medically directed interdisciplinary team; and

(C)

may be provided in a home [ residence ], nursing facility, residential unit, [ independent living environment, ] or inpatient unit according to need. These services do not include inpatient care normally provided in a licensed hospital to a terminally ill person who has not elected to be a hospice client.

(38)

[ (37) ] Independent living environment--A client's individual residence, which may include a group home or foster home, or other settings where a client participates in activities, including school, work, or church.

(39)

[ (38) ] Individual/family choice and control--Individuals and families who express preferences and make choices about how their support service needs are met.

(40)

[ (39) ] Inpatient unit--A facility that provides a continuum of medical or nursing care and other hospice services to clients admitted into the unit and that is in compliance with the conditions of participation for inpatient units adopted under Social Security Act, Title XVIII (42 United States Code §1395 et seq.) and standards adopted under this chapter.

(41)

[ (40) ] Interdisciplinary team--

[ (A)

for home dialysis designation, the physician, the registered nurse, the dietitian, and the qualified social worker responsible for planning the care delivered to the home staff-assisted dialysis patient; or]

[ (B) ]

[ a ] A group of individuals who work together in a coordinated manner to provide hospice services and must include a physician, registered nurse, social worker, and counselor.

(42)

[ (41) ] Licensed vocational nurse--A person who is currently licensed under Occupations Code, Chapter 302 [ Texas Civil Statutes, Article 4528c ], as a licensed vocational nurse.

(43)

[ (42) ] Long-term program--For home dialysis designation, the written documentation of the selection of a suitable treatment modality and dialysis setting which has been selected by the client and the interdisciplinary team.

(44)

[ (43) ] Manager--A person having a contractual relationship to provide management services to a home and community support services agency for the overall operation of a home and community support services agency including administration, staffing, or delivery of services. Examples of contracts for services that will not be considered to be contracts for management services include contracts solely for maintenance, laundry, or food services.

(45)

[ (44) ] Medication administration record--A record used to document the administration of a client's medications.

(46)

[ (45) ] Medication list--A list of a client's medications that includes the recommended dosage and the frequency and method of administration. The medication list is used to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, and contraindications. [ The medication list does not include a medication profile. ]

(47)

[ (46) ] Notarized copy--A sworn affidavit stating that attached copies are true and correct copies of the original documents.

(48)

[ (47) ] Nursing facility--An institution licensed as a nursing home under the Health and Safety Code, Chapter 242.

(49)

[ (48) ] Nutritional counseling--Advising and assisting individuals or families on appropriate nutritional intake by integrating information from the nutrition assessment with information on food and other sources of nutrients and meal preparation consistent with cultural background and socioeconomic status, with the goal being health promotion, disease prevention, and nutrition education. Nutritional counseling may include, but is not limited to, the following:

(A)

dialogue with the client to discuss current eating habits, exercise habits, food budget and problems with food preparation;

(B)

discussion of dietary needs to help the client understand why certain foods should be included or excluded from the client's diet and to help with adjustment to the new or revised or existing diet plan;

(C)

a personalized written diet plan as ordered by the client's physician or practitioner, to include instructions for implementation;

(D)

providing the client with motivation to help him or her understand and appreciate the importance of the diet plan in getting and staying healthy; or

(E)

working with the client or the client's family members by recommending ideas for meal planning, food budget planning, and appropriate food gifts.

(50)

[ (49) ] Occupational therapist--A person who is currently licensed under the Occupational Therapy Practice Act, Occupations Code, Chapter 454 [ Texas Civil Statutes, Article 8851 ], as an occupational therapist.

(51)

Original active client record--A record composed first-hand for a client currently receiving services.

(52)

[ (50) ] Owner--One of the following persons which will hold or does hold a license issued under the statute in the person's name or the person's assumed name:

(A)

a corporation;

(B)

a limited liability company;

(C)

an individual;

(D)

a partnership if a partnership name is stated in a written partnership agreement or an assumed name certificate;

(E)

all partners in a partnership if a partnership name is not stated in a written partnership agreement or an assumed name certificate; or

(F)

all co-owners under any other business arrangement.

(53)

[ (51) ] Palliative care--Intervention services that focus primarily on the reduction or abatement of physical, psychosocial, and spiritual symptoms of a terminal illness.

(54)

[ (52) ] Parent agency--The agency that develops and maintains administrative controls and provides supervision of branch offices and alternate delivery sites.

(55)

[ (53) ] Parent company--A person, other than an individual, who has a direct 100% ownership interest in the owner of an agency.

(56)

[ (54) ] Person--An individual, corporation, or association.

(57)

[ (55) ] Personal assistance services--Routine ongoing care or services required by an individual in a residence or independent living environment that enable the individual to engage in the activities of daily living or to perform the physical functions required for independent living, including respite services. The term includes health-related services performed under circumstances that are defined as not constituting the practice of professional nursing by the Board of Nurse Examiners through a memorandum of understanding with DHS in accordance with Health and Safety Code, [ §167 ] §142.016, and health-related tasks provided by unlicensed personnel under the delegation of a registered nurse [ or physician ].

(58)

[ (56) ] Physical therapist--A person who is currently licensed under Occupations Code, Chapter 453 [ Texas Civil Statutes, Article 4512e ], as a physical therapist.

(59)

[ (57) ] Physician--A person [ who is currently licensed under the laws of a state within the United States and in which the person practices medicine and ] who holds a doctor of medicine or doctor of osteopathy degree and is currently licensed and practicing medicine under the laws of the state of Texas, Oklahoma, New Mexico, Arkansas, or Louisiana .

(60)

[ (58) ] Physician assistant--A person who is licensed under the Physician Assistant Licensing Act, Occupations Code, Chapter 204 [ Texas Civil Statutes, Article 4495-1 ], as a physician assistant.

(61)

[ (59) ] Physician-delegated [ Physician delegated ] tasks--Tasks performed in accordance with the Medical Practice Act, Occupations Code, Chapter 157 [ Texas Civil Statutes, Article 4495d, §3.06 ], including orders signed by a physician which specify the delegated task(s), the individual to whom the task(s) is delegated, and the client's name.

(62)

[ (60) ] Place of business--An office of a home and community support services agency that maintains client records or directs home health, hospice, or personal assistance services. The term does not include an administrative support site.

(63)

[ (61) ] Plan of care--The written orders of a practitioner for a client who requires skilled services.

(64)

[ (62) ] Practitioner--A person who is currently licensed in a state in which the person practices as a physician, dentist, podiatrist, or a physician assistant, or a person who is a registered nurse registered with the Board of Nurse Examiners for the State of Texas as an advanced practice nurse.

(65)

[ (63) ] Presurvey conference--A conference held with DHS [ department ] staff and the applicant or his or her representatives to review licensure standards and survey documents and provide consultation prior to the on-site licensure survey.

(66)

[ (64) ] Progress note--A dated and signed written notation by agency personnel summarizing facts about care and the client's response during a given period of time.

(67)

[ (65) ] Psychoactive treatment--The provision of a skilled nursing visit to a client with a psychiatric diagnosis under the direction of a physician that includes one or more of the following:

(A)

assessment of alterations in mental status or evidence of suicide ideations or tendencies;

(B)

teaching coping mechanisms or skills;

(C)

counseling activities; or

(D)

evaluation of the plan of care.

(68)

[ (66) ] Registered nurse (RN)--A person who is currently licensed under the Nursing Practice Act, Occupations Code, Chapter 301, [ Texas Civil Statutes, Article 4513 et seq. ] as a registered nurse.

(69)

[ (67) ] Registered nurse delegation--Delegation by a registered nurse in accordance with 22 TAC Chapter 218 [ §§218.1-218.11 ] ( concerning Delegation of Selected Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel).

(70)

[ (68) ] Residence--A place where a person resides and includes a home, a nursing facility, a convalescent home, [ an independent living environment ], or a residential unit. [ A residence includes a group or a foster home. ]

(71)

[ (69) ] Residential unit--A facility that provides living quarters and hospice services to clients admitted into the unit and that is in compliance with standards adopted under the Health and Safety Code, Chapter 142 [ Texas Special Care Facility Licensing Act, Health and Safety Code, Chapter 248 ].

(72)

[ (70) ] Respiratory therapist--A person who is currently licensed under Occupations Code, Chapter 604 [ Texas Civil Statutes, Article 4512l ], as a respiratory care practitioner.

(73)

[ (71) ] Respite services--Support options that are provided temporarily for the purpose of relief for a primary caregiver in providing care to individuals of all ages with disabilities or at risk of abuse or neglect. [ Respite services may be provided under home health, hospice, or personal assistance services depending on the needs of the client. ]

(74)

[ (72) ] Section [ Sections ]-- A reference to a specific rule in Chapter 97 of this title ( concerning Licensing Standards for Home and Community Support Services Agencies [ Agency ]).

(75)

[ (73) ] Service area--The geographic area(s) established by an agency in which all or some of the agency's services are available.

(76)

[ (74) ] Skilled services--Services in accordance with a plan of care that require the skills of a:

(A)

registered nurse;

(B)

licensed vocational nurse;

(C)

physical, occupational, or respiratory therapist;

(D)

speech-language pathologist;

(E)

audiologist;

(F)

social worker; or

(G)

dietitian.

(77)

[ (75) ] Social worker--A person who is currently licensed as a social worker under Occupations Code, Chapter 505 [ Human Resource Code, Chapter 50 ].

(78)

[ (76) ] Speech-language pathologist--A person who is currently licensed under [ the ] Occupations Code, Chapter 401 [ Texas Civil Statutes, Article 4512j ], as a speech-language pathologist.

(79)

[ (77) ] Statute--The Health and Safety Code, Chapter 142.

(80)

[ (78) ] Supervising nurse--The person responsible for supervising skilled services provided by an agency and who has the qualifications described in §97.244(b) of this title (relating to Staffing Qualifications and Conditions) [ §97.21(b)(3)(C) of this title (relating to Licensure Requirements and Standards for Agencies Providing Licensed Home Health, Licensed and Certified Home Health, or Hospice Services) ]. This person may also be known as the director of nursing or similar title.

(81)

[ (79) ] Supervision--Authoritative procedural guidance by a qualified person for the accomplishment of a function or activity with initial direction and periodic inspection of the actual act of accomplishing the function or activity.

(82)

[ (80) ] Support services--Social, spiritual, and emotional care provided to a client and a client's family by a hospice.

(83)

[ (81) ] Survey--An inspection or investigation conducted by a DHS representative [ of the department ] to determine if a licensee is in compliance with the statute and this chapter. [ A survey may be conducted onsite, by mail, by telephone or by electronic communication methods. ]

(84)

[ (82) ] Terminal illness--An illness for which there is a limited prognosis if the illness runs its usual course.

(85)

[ (83) ] Unlicensed person--An individual who is not licensed as a health care professional. The term includes, but is not limited to, home health aides, medication aides permitted by DHS [ the department ], and other individuals providing personal care or assistance in health services.

(86)

[ (84) ] Volunteer--An individual who provides assistance to a home and community support services agency without compensation other than reimbursement for actual expenses. [ A volunteer must meet the same requirements and standards in this chapter as apply to an employee of the agency doing the same activities unless the volunteer is exempt under this chapter from certain requirements or standards. ]

§97.3.Licensing Fees.

(a)

(No change.)

(b)

If an applicant for an initial license [ , ] based on a change of ownership [ , ] makes late application for a license to the Texas Department of Human Services (DHS) in accordance with §97.13(b)(2)(C)(iii) of this title (relating to Change of Ownership [ and Services ]), the applicant must submit the appropriate initial license fee as set out in subsection (a) of this section plus an additional late fee of $250.

(c)-(e)

(No change.)

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102148

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


Subchapter B. APPLICATION AND ISSUANCE OF A LICENSE

40 TAC §§97.11, 97.13 - 97.16

The amendments are proposed under the Health and Safety Code, Chapter 142, which provides the department with the authority to adopt rules for the licensing and regulation of home and community support services agencies.

The amendments implement the Health and Safety Code, Chapter 142.001-142.030.

§97.11.Application and Issuance of Initial License.

(a)-(f)

(No change.)

(g)

The applicant must apply for a license in accordance with this subsection.

(1)-(2)

(No change.)

(3)

The following items must accompany the application form and must be originals or notarized copies:

(A)

a description of the agency's service area. The service area must be established in accordance with §97.220 of this title (relating to Service Areas);

[ (i)

§97.21(a)(7) of this title (relating to Licensure Requirements and Standards for Agencies Providing Licensed Home Health, Licensed and Certified Home Health, or Hospice Services) for agencies providing licensed home health, licensed and certified home health, or hospice services; or]

[ (ii)

§97.26(b) of this title (relating to Standards for Personal Assistance Services) for agencies with the category of personal assistance services;]

(B)-(J)

(No change.)

(K)

for a parent agency:

(i)-(iv)

(No change.)

(v)

the resume or curriculum vitae of the agency administrator. The resume or curriculum vitae must reflect that the administrator has the qualifications described in §97.244(a) of this title (relating to Staffing Qualifications and Conditions); [ : ]

[ (I)

§97.21(b)(3)(B) of this title for agencies providing licensed home health, licensed and certified home health, or hospice services; or]

[ (II)

§97.26(g) of this title for agencies providing personal assistance services; and]

(vi)

the resume or curriculum vitae of the agency supervising nurse (if applicable). The resume or curriculum vitae must reflect that the supervising nurse has the qualifications described in §97.244(b) [ §97.21(b)(3)(C) ] of this title (relating to Staffing Qualifications and Conditions) ;

(L)-(S)

(No change.)

(T)

notice that the agency has attended a presurvey conference at the office designated by DHS, or that the designated survey office has waived the presurvey conference.

(i)-(ii)

(No change.)

(iii)

The designated survey office must verify compliance with the applicable provisions of this chapter and recommend that the agency be issued an initial license or that the application be denied pursuant to §97.601 [ §97.52 ] of this title (relating to License Denial, Suspension, or Revocation [ Enforcement Action ]); and

(U)-(V)

(No change.)

(4)-(6)

(No change.)

(h)-(i)

(No change.)

(j)

A DHS surveyor will conduct an onsite survey of the agency after the issuance of the initial license.

(1)-(3)

(No change.)

(4)

At the time of the initial survey, the agency must:

(A)

(No change.)

(B)

assure that the administrator and supervising nurse or designee(s), if applicable, are present at the entrance conference, available during the survey, and present at the exit conference. If the administrator and supervising nurse or designee(s) are not present at the surveyor's arrival, the survey will not be conducted, the initial license may be revoked and the renewal license denied in accordance with §97.601 [ §97.52 ] of this title (relating to License Denial, Suspension, or Revocation [ Enforcement Action ]).

(5)

(No change.)

(6)

By applying for or holding a license, an agency consents to entry and survey by DHS or a representative of DHS to verify compliance with the statute or this chapter. The agency must provide a DHS representative entry to the agency and access to documents in accordance with §97.501(a) [ §97.51(a) ] of this title (relating to Survey Procedures).

(k)

A person who has requested the category of licensed and certified home health services on the initial license application must also make application for certification by the United States Department of Health and Human Services (USDHHS) as a Medicare certified agency under the Social Security Act, Title XVIII.

(1)-(2)

(No change.)

(3)

If HCFA denies certification to the person or if the person withdraws application for participation in the Medicare program, the person will retain the category of licensed home health services. An agency's retention of the licensed home health services category does not preclude DHS from taking enforcement action, as appropriate, under Subchapter F of this chapter (relating to Enforcement) [ §97.52 of this title (relating to Enforcement Action) ].

(l)

Continuing compliance with the minimum standards and the provisions of this chapter for the services authorized to be provided under the license is required during the initial licensing period in order for a first renewal license to be issued.

[ (1)

An agency authorized under the license to provide licensed home health, licensed and certified home health, or hospice services must comply with §97.21 of this title.]

[ (2)

An agency authorized under the license to provide licensed home health services must comply with §97.22 of this title (relating to Standards for Licensed Home Health Services).]

[ (3)

An agency authorized under the license to provide licensed and certified home health services must comply with §97.23 of this title (relating to Standards for Licensed and Certified Home Health Services).]

[ (4)

An agency authorized under the license to provide home dialysis must comply with §97.24 of this title (relating to Standards for Home Dialysis Designation).]

[ (5)

An agency authorized under the license to provide hospice services must comply with §97.25 of this title (relating to Standards for Hospice Services).]

[ (6)

An agency which holds a license with the category of personal assistance services must comply with §97.26 of this title (relating to Standards for Personal Assistance Services).]

(m)

If DHS determines that compliance with the minimum standards and the provisions of this chapter is not substantiated after the issuance of the initial license, DHS [ the department ] may propose to revoke the initial license and deny the first renewal license and must notify the applicant of a license revocation and denial as provided in §97.601 of this title (relating to License Denial, Suspension, or Revocation) [ §97.52 of this title (relating to Enforcement Action) ].

(n)

(No change.)

[ (o)

A person may not engage in the business of providing home health, hospice, or personal assistance services, or represent to the public that the person is a provider of home health, hospice, or personal assistance services for pay or other consideration without a license.]

§97.13.Change of Ownership [ or Services ].

(a)

(No change.)

(b)

Agency procedures for change of ownership.

(1)-(3)

(No change.)

(4)

Failure to comply with the application procedures set out in this section may result in an enforcement action(s) under §97.601 [ §97.52 ] of this title (relating to License Denial, Suspension, or Revocation [ Enforcement Action ]).

(5)-(6)

(No change.)

(7)

DHS may deny issuance of a license for any of the reasons specified in §97.601 [ §97.52(a) ] of this title (relating to License Denial, Suspension, or Revocation [ Enforcement Action ]).

(8)

(No change.)

(c)

(No change.)

[ (d)

Notification procedures for agency name change.]

[ (1)

If an agency changes the agency's name (legal entity or doing business as), but does not undergo a change of ownership as defined in subsection (a)(2) of this section, the agency must provide:]

[ (A)

written notification to DHS within five business days prior the effective date of change;]

[ (B)

a copy of a certificate of amendment from the Secretary of State's office or other governmental authority(ies), e.g., an assumed name certificate, reflecting the name change to DHS within 30 days of receipt of the certificate; and]

[ (C)

a copy of the agency's current federal tax payer identification number.]

[ (2)

On receipt and verification of the certificate of amendment and the current federal tax payor identification number, DHS will provide the agency with a notification of change in the agency's new name.]

[ (e)

Service change/agency closure procedures.]

[ (1)

An agency must provide written notification to DHS within five calendar days of the agency's receipt of notice of change in state or federal certification or accreditation status. The licensee must include a copy of the notice of change with its written notice to DHS.]

[ (2)

An agency must notify DHS in writing within five calendar days prior to the cessation of operation of the agency, branch office, or alternate delivery site.]

[ (A)

The agency must include in the written notice the reason for closure, the location of the client records, and the name and address of the client record custodian.]

[ (B)

If the agency closes with an active client roster, the agency must transfer a copy of the active client record with the client to the receiving agency in order to assure continuity of care and services to the client.]

[ (C)

The agency must mail or return the initial license or renewal license to DHS at the end of the day services were terminated.]

[ (D)

Continuing to operate after the closure date specified in the notice may result in enforcement action.]

[ (f)

Procedures for adding or deleting a category to the license. To add or delete a category to the license, the agency must provide written notification to DHS at least 30 calendar days prior to the addition or deletion of the category.]

[ (1)

DHS will approve or disapprove the addition of a category.]

[ (A)

At the discretion of DHS, an agency must attend a presurvey conference at the designated survey office prior to DHS approving the addition of a category.]

[ (B)

If disapproved, DHS will inform the agency of the reason for disapproval.]

[ (2)

At the discretion of DHS, an on-site survey may be conducted following the approval of a category.]

[ (3)

DHS's receipt of an agency request to delete a category from the license does not preclude DHS from taking enforcement action as appropriate in accordance with §97.52 of this title (relating to Enforcement Action).]

§97.14.Application and Issuance of a Branch Office License.

(a)

The Texas Department of Human Services (DHS) may issue a branch office license to a person who holds a current agency license to provide home health or personal assistance services. A person who holds a current agency license is eligible to apply for a branch office license:

(1)

(No change.)

(2)

if enforcement action against the agency license is not proposed under Subchapter F [ §97.52 ] of this title (relating to Enforcement [ Action ]).

(b)

(No change.)

(c)

The parent agency applicant must submit to DHS:

(1)-(4)

(No change.)

(5)

a description of the branch office's service area. The service area must meet the criteria in §97.321(d) [ §97.27 ] of this title (relating to Standards for Branch Offices).

(d)-(g)

(No change.)

(h)

DHS may propose denial of the application according to §97.601 [ §97.52 ] of this title (relating to License Denial, Suspension, or Revocation [ Enforcement Action ]) after consideration of the designated survey office's recommendation.

(i)-(k)

(No change.)

(l)

The branch office must comply with §97.321 [ §97.27 ] of this title (relating to Standards for Branch Offices) and the standards relating to the category(ies) authorized under the license.

§97.15.Application and Issuance of an Alternate Delivery Site License.

(a)

The Texas Department of Human Services (DHS) may issue an alternate delivery site license to a person who holds a current agency license to provide hospice services. A person who holds a current agency license to provide hospice services is eligible to apply for an alternate delivery site license:

(1)

(No change.)

(2)

if enforcement action against the agency license is not proposed under Subchapter F of this chapter [ §97.52 of this title ] (relating to Enforcement [ Action ]).

(b)

(No change.)

(c)

The hospice must submit to DHS:

(1)-(4)

(No change.)

(5)

a description of the alternate delivery site's service area. The service area must meet the criteria in §97.322(d) [ §97.28 ] of this title (related to Standards for Alternate Delivery Sites).

(d)-(g)

(No change.)

(h)

DHS may propose denial of the application according to §97.601 [ §97.52 ] of this title relating to License Denial, Suspension, or Revocation) after consideration of the designated survey office's recommendation.

(i)

(No change.)

(j)

The alternate delivery site must comply with §97.403 [ §97.25 ] of this title (relating to Standards Specific to Agencies Licensed to Provide [ for ] Hospice Services) and §97.322 [ §97.28 ] of this title (relating to Standards for Alternate Delivery Sites) . The designated survey office will conduct an on-site survey after a license has been issued to verify compliance with §97.403 [ §97.25 ] of this title (relating to Standards Specific to Agencies Licensed to Provide [ for ] Hospice Services) and §97.322 [ §97.28 ] of this title (relating to Standards for Alternate Delivery Sites).

(k)

(No change.)

§97.16.Time Periods for Processing and Issuing a License.

(a)

General.

(1)-(3)

(No change.)

(4)

An application for a change of ownership license is complete when DHS has received, reviewed, and found acceptable the information described in §97.13 of this title (relating to Change of Ownership [ or Services ]).

(b)-(d)

(No change.)

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102149

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


Subchapter C. SERVICE STANDARDS

40 TAC §§97.21 - 97.28

(Editor's note: The text of the following sections proposed for repeal will not be published. The sections may be examined in the offices of the Texas Department of Human Services or in the Texas Register office, Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)

The repeals are proposed under the Health and Safety Code, Chapter 142, which provides the department with the authority to adopt rules for the licensing and regulation of home and community support services agencies.

The repeals implement the Health and Safety Code, Chapter 142.001- 142.030.

§97.21.Licensure Requirements and Standards for Agencies Providing Licensed Home Health, Licensed and Certified Home Health, or Hospice Services.

§97.22.Standards for Licensed Home Health Services.

§97.23.Standards for Licensed and Certified Home Health Services.

§97.24.Standards for Home Dialysis Designation.

§97.25.Standards for Hospice Services.

§97.26.Standards for Personal Assistance Services.

§97.27.Standards for Branch Offices.

§97.28.Standards for Alternate Delivery Sites.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102150

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


Subchapter D. ENFORCEMENT

40 TAC §§97.51 - 97.54

(Editor's note: The text of the following sections proposed for repeal will not be published. The sections may be examined in the offices of the Texas Department of Human Services or in the Texas Register office, Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)

The repeals are proposed under the Health and Safety Code, Chapter 142, which provides the department with the authority to adopt rules for the licensing and regulation of home and community support services agencies.

The repeals implement the Health and Safety Code, Chapter 142.001- 142.030.

§97.51.Survey Procedures.

§97.52.Enforcement Action.

§97.53.Complaints.

§97.54.Criminal History Checks.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102151

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


Subchapter E. HOME HEALTH AIDES AND MEDICATION AIDES

40 TAC §97.61, §97.62

(Editor's note: The text of the following sections proposed for repeal will not be published. The sections may be examined in the offices of the Texas Department of Human Services or in the Texas Register office, Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)

The repeals are proposed under the Health and Safety Code, Chapter 142, which provides the department with the authority to adopt rules for the licensing and regulation of home and community support services agencies.

The repeals implement the Health and Safety Code, Chapter 142.001- 142.030.

§97.61.Home Health Aides.

§97.62.Home Health Medication Aides.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102152

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


Subchapter F. ADVISORY COMMITTEES

40 TAC §97.71, §97.72

(Editor's note: The text of the following sections proposed for repeal will not be published. The sections may be examined in the offices of the Texas Department of Human Services or in the Texas Register office, Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)

The repeals are proposed under the Health and Safety Code, Chapter 142, which provides the department with the authority to adopt rules for the licensing and regulation of home and community support services agencies.

The repeals implement the Health and Safety Code, Chapter 142.001- 142.030.

§97.71.Home and Community Support Services Advisory Committee.

§97.72.Texas Department of Health {Texas Department of Human Services} /Board of Nurse Examiners Memorandum of Understanding Advisory Committee.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102153

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


Subchapter C. MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES

1. GENERAL PROVISIONS

40 TAC §97.201

The new section is proposed under the Health and Safety Code, Chapter 142, which provides the department with the authority to adopt rules for the licensing and regulation of home and community support services agencies.

The new section implements the Health and Safety Code, Chapter 142.001-142.030.

§97.201.Applicability.

This subchapter applies to all home and community support services agencies providing licensed home health, licensed and certified home health, hospice, or personal assistance services.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102154

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


2. CONDITIONS OF LICENSE

40 TAC §§97.211 - 97.222

The new sections are proposed under the Health and Safety Code, Chapter 142, which provides the department with the authority to adopt rules for the licensing and regulation of home and community support services agencies.

The new sections implement the Health and Safety Code, Chapter 142.001-142.030.

§97.211.Display of License.

The license must be displayed in a conspicuous place in the designated place of business. If the information on the license is officially amended during the licensure period, a notice must be posted beside the license to provide public notice of the change.

§97.212.License Alteration Prohibited.

A license may not be altered.

§97.213.Agency Relocation.

(a)

A license must not be transferred from one location to another without prior notification to the Texas Department of Human Services (DHS). If an agency is considering relocation, the agency must notify DHS 30 calendar days prior to the intended relocation. DHS will provide written notification to the agency amending the annual license to reflect the new location.

(b)

The relocation of either a branch office or alternate delivery site to a different parent agency requires submission of a new application for the branch office or alternate delivery site, compliance with §97.14 of this title (relating to Application and Issuance of a Branch Office License) and §97.15 of this title (relating to Application and Issuance of an Alternate Delivery Site License) as appropriate, and approval of the application by DHS.

§97.214.Telephone Number Change.

An agency must notify the Texas Department of Human Services in writing prior to a change in its telephone number.

§97.215.Notification Procedures for Agency Name Change.

(a)

If an agency changes the agency's name (legal entity or doing business as), but does not undergo a change of ownership as defined in §97.13(a)(2) of this title (relating to Change of Ownership), the agency must provide to the Texas Department of Human Services (DHS):

(1)

written notification within five business days prior the effective date of change;

(2)

a copy of a certificate of amendment from the Secretary of State's office or other governmental authority(ies), such as, an assumed name certificate, reflecting the name change within 30 days of receipt of the certificate; and

(3)

a copy of the agency's current federal tax payer identification number.

(b)

On receipt and verification of the certificate of amendment and the current federal tax payor identification number, DHS will provide the agency with a notification of change in the agency's new name.

§97.216.Change in Agency Certification or Accreditation Status.

An agency must provide written notification to the Texas Department of Human Services (DHS) within five calendar days of the agency's receipt of notice of change in state or federal certification or accreditation status. The licensee must include a copy of the notice of change with its written notice to DHS.

§97.217.Agency Closure Procedures.

An agency must notify the Texas Department of Human Services (DHS) in writing within five calendar days prior to the cessation of operation of the agency, branch office, or alternate delivery site.

(1)

The agency must include in the written notice the reason for closure, the location of the client records (active and inactive), and the name and address of the client record custodian.

(2)

If the agency closes with an active client roster, the agency must transfer a copy of the active client record with the client to the receiving agency in order to assure continuity of care and services to the client.

(3)

The agency must mail or return the initial license or renewal license to DHS at the end of the day services were terminated.

(4)

Continuing to operate after the closure date specified in the notice may result in enforcement action.

§97.218.Agency Organizational Changes.

An agency must notify the Texas Department of Human Services (DHS) in writing immediately of any change in its agency administrator, controlling person, or chief financial officer. DHS will perform a criminal history check for a change in the administrator and the chief financial officer.

§97.219.Procedures for Adding or Deleting a Category to the License.

To add or delete a category to the license, the agency must provide written notification to the Texas Department of Human Services (DHS) at least 30 calendar days prior to the addition or deletion of the category.

(1)

Additions. DHS will approve or disapprove the addition of a category.

(A)

At the discretion of DHS, an agency must attend a presurvey conference at the designated survey office prior to DHS approving the addition of a category.

(B)

DHS will either approve or deny the addition within 30 days. An agency may not provide the service until written notice of approval has been received from DHS.

(C)

If disapproved, DHS will inform the agency of the reason for disapproval.

(D)

At the discretion of DHS, an on-site survey may be conducted following the approval of a category.

(2)

Deletions. DHS's receipt of an agency request to delete a category from the license does not preclude DHS from taking enforcement action as appropriate in accordance with Subchapter F of this chapter (relating to Enforcement Action).

§97.220.Service Areas.

(a)

Licensed service area. An agency must provide services only within its licensed service area.

(b)

Staffing. The agency must maintain adequate staff to provide services and to supervise the provision of services within the service area.

(c)

Expansion of service area. An agency may expand its service area at any time during the licensure period.

(1)

Unless exempted under paragraph (2) of this subsection, to expand its service area, an agency must submit to the Texas Department of Human Services (DHS) a written notice 30 days prior to the expansion which includes:

(A)

revised boundaries of the agency's original service area;

(B)

the effective date of the expansion; and

(C)

an updated list of management and supervisory personnel (including names), if changes are made.

(2)

An agency will be exempted from the 30-day written notice requirement under paragraph (1) of this subsection, if DHS determines an emergency situation exists that would impact client health and safety. An agency must notify DHS immediately of a possible emergency. DHS will determine if an exemption can be granted.

(d)

Reduction of service area. An agency may reduce its service area at any time during the licensure period by sending DHS written notification of the reduction, the revised boundaries of the agency's original service area, and the effective date of the reduction.

(e)

Branch office and alternate delivery site location. A branch office or alternate delivery site must be located within the parent agency's service area.

§97.221.Changing Ownership.

If there is a change of ownership as defined in §97.13 of this title (relating to Change of Ownership), the license is void on the effective date of the change. The prospective new owners must comply with §97.13 of this title (relating to Change of Ownership).

§97.222.Compliance.

An agency must maintain satisfactory compliance with all the provisions of the statute and this chapter to maintain licensure.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102155

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


3. AGENCY ADMINISTRATION

40 TAC §§97.241 - 97.257

The new sections are proposed under the Health and Safety Code, Chapter 142, which provides the department with the authority to adopt rules for the licensing and regulation of home and community support services agencies.

The new sections implement the Health and Safety Code, Chapter 142.001-142.030.

§97.241.Management and Ownership.

The licensee is responsible for the conduct of the agency and assumes full legal responsibility for adopting, implementing, enforcing, and monitoring the written policies required throughout this chapter that govern the home and community support services agency's total operation and for ensuring that these policies comply with the Act and the applicable provisions of this chapter and are administered to provide safe, professional, quality health care.

§97.242.Organizational Structure and Lines of Authority.

(a)

An agency must prepare a written document that identifies the agency's organizational structure. The document may be either in the form of a chart or a narrative.

(b)

The written organizational structure must clearly define, at a minimum:

(1)

all services that are provided by the agency;

(2)

the governing body, the administrator, the supervising nurse, and staff, as appropriate, based on services that are provided by the agency; and

(3)

the lines of authority and the delegation of responsibility down to and including the client care level.

§97.243.Management Responsibilities.

(a)

Administrator. The licensee must appoint an administrator who meets the qualifications and conditions set out in §97.244(a) of this title (relating to Staffing Qualifications and Conditions). The licensee must also designate in writing a person who meets the qualifications of an administrator to act in the absence of the administrator.

(1)

The administrator must be responsible for implementing and supervising the administrative policies of the agency and supervising the provision of all services. At a minimum, the administrator must:

(A)

organize and direct the agency's ongoing functions;

(B)

assure that the documentation of services provided is accurate and timely;

(C)

employ qualified, competent personnel;

(D)

ensure adequate staff education and evaluations;

(E)

ensure the accuracy of public information materials and activities;

(F)

implement an effective budgeting and accounting system; and

(G)

supervise and evaluate client satisfaction survey reports on all clients served.

(2)

The administrator or designee must be available during the agency's usual working hours.

(b)

Supervising nurse.

(1)

An agency with a license to provide licensed home health, licensed and certified home health, or hospice services must have a supervising nurse.

(2)

The administrator must appoint a supervising nurse who meets the qualifications set out in §97.244(b) of this title (relating to Staffing Qualifications and Conditions). The administrator must also appoint a similarly qualified alternate to serve as supervising nurse in the absence of the supervising nurse.

(3)

The supervising nurse or designee must:

(A)

be available to the agency at all times. The supervising nurse or designee may be available in person or via telecommunication;

(B)

participate in activities relevant to professional services furnished including the development of qualifications and assignment of agency personnel;

(C)

assure that a client's plan of care is executed as written;

(D)

assure that a reassessment of a client's needs is performed by the appropriate health care professional:

(i)

when there is a significant health status change in the client's condition;

(ii)

at the physician's request; or

(iii)

after hospital discharge.

(4)

The supervising nurse may also be the administrator of the agency if the supervising nurse meets the qualifications of an administrator described in §97.244(a) of this title (relating to Staffing Qualifications and Conditions).

(5)

An agency that provides only physical, occupational, speech, or respiratory therapy; medical social services; or nutritional counseling is not required to have a supervising nurse. Supervision of these services must be provided by the appropriate licensed professional, such as a physical therapist supervising physical therapy services.

(c)

Supervision of branch offices and alternative delivery sites. An agency must adopt and enforce a written policy relating to the supervision of branch offices or alternate delivery sites, if established. This policy must be consistent with:

(1)

for a branch office, §97.14 of this title (relating to Application and Issuance of a Branch Office License) and §97.321 of this title (relating to Standards for Branch Offices); or

(2)

for an alternate delivery site, §97.15 of this title (relating to Application and Issuance of a Branch Office License) and §97.322 of this title (relating to Standards for Alternate Delivery Sites).

§97.244.Staffing Qualifications and Conditions.

(a)

Administrator, including the alternate or other designee.

(1)

Qualifications. The administrator must either:

(A)

be a physician, registered nurse, social worker, or nursing home administrator; or

(B)

have a baccalaureate or postgraduate degree in administration in a health or human services field and at least one year of full-time administrative experience as the administrator of an agency or licensed health care facility; or

(C)

have a high school diploma or a GED and have training and experience in health service administration and at least one year of full-time supervisory or administrative experience in a facility or agency, such as a hospital, nursing facility, home health care, hospice, or related health programs; or

(D)

if the agency is licensed to deliver personal assistance services only, have a high school diploma or a general equivalency degree (GED) and at least one year experience or training in caring for individuals with functional disabilities.

(2)

Conditions. The administrator must:

(A)

be able to read, write, and comprehend English;

(B)

not have been employed in the last one year as an administrator with another agency at the time the agency was cited with violations of the statute or this chapter which resulted in enforcement action taken against the agency. For purposes of this subparagraph only, the term "enforcement action" means license revocation, suspension, emergency suspension, or denial of a license or injunction action but does not include administrative or civil penalties. If DHS prevails in one enforcement action, such as injunctive action, against the agency but also proceeds with another enforcement action, such as revocation, based on some or all of the same violations, but DHS does not prevail in the second action (the agency prevails), the prohibition in this subparagraph does not apply; and

(C)

not have been convicted of a felony or misdemeanor listed in §97.601(b)(2) of this title (relating to License Denial, Suspension, and Revocation); and

(D)

have documented completion of a minimum of six clock hours per year at a health service administration seminar, the subject at which may include cost reports, OSHA requirements for health care providers, home and community support services rules and regulations, quality improvement for health care providers, competency documentation and evaluation for skilled staff, and peer review reporting.

(b)

Supervising nurse qualifications. The supervising nurse and the designated alternate must:

(1)

be registered nurses licensed in the state of Texas or in accordance with the Board of Nurse Examiners rules for Nurse Licensure Compact (NLC); and

(2)

have at least two years of current experience as registered nurses in a health care setting that provides care for children, adults, or geriatric clients. For experience to be considered current, it must have been obtained within the last three years and prior to assuming the role of supervising nurse. One year of experience working as a consultant or in some other capacity that entailed administering home health care standards may be substituted for one year of the required nursing experience; or

(3)

if delivering home dialysis services, be:

(A)

a registered nurse licensed in the state of Texas or in accordance with the Board of Nurse Examiners rules for Nurse Licensure Compact (NLC) who:

(i)

has at least three years current experience in hemodialysis; or

(ii)

has at least two years experience as an RN and holds a current certification from a nationally recognized board in nephrology nursing or hemodialysis; or

(B)

a nephrologist or physician with training or demonstrated experience in the care of ESRD clients.

§97.245.Staffing Policies.

An agency must adopt and enforce written policies that govern all personnel staffed by the agency. The policies must:

(1)

include requirements for orientation; training; and demonstration of competency for tasks when competency can not be determined through education, license or certification, or experience of all employees, volunteers (if used), and contractors (if used) to the policies, procedures, and objectives of the agency and participation by all personnel in employee training specific to their job. The agency must provide a continuing systematic program for the training of its employees. The staff, including volunteers (if used) and contractors (if used), must be properly oriented to tasks performed, and these individuals must be informed of changes in techniques, philosophies, goals, client's rights, and products, relating to the client's care;

(2)

address participation by all personnel in appropriate employee development programs;

(3)

include a written job description (statement of those functions and responsibilities which constitute job requirements) and job qualifications (specific education and training necessary to perform the job) for each position within the agency;

(4)

include procedures for processing criminal history checks of unlicensed personnel in accordance with §97.247 of this title (relating to Criminal History Checks for Unlicensed Personnel);

(5)

ensure annual evaluation of employee and volunteer performance;

(6)

address employee and volunteer disciplinary action(s) and procedures;

(7)

if volunteers are used by the agency, address the use of volunteers. The policy must be in compliance with §97.248 of this title (relating to Volunteers);

(8)

specify the qualifications, experience, and training in pediatrics required for any registered nurse who provides or supervises direct care staff in the provision of services to pediatric clients; and

(9)

include a requirement that all personnel who are direct care staff and who have direct contact with clients (employed by or under contract with the facility) sign a statement that they have read, understand, and will comply with agency policies.

§97.246.Personnel Records.

(a)

An individual personnel record must be maintained on each person employed by the agency, including volunteers. All information must be kept current. A personnel record must include, but not be limited to, the following:

(1)

job description and qualifications. In lieu of the job description and qualifications for employment, the personnel record may include a statement signed by the employee or volunteer that he has read the job description and qualifications for the position accepted;

(2)

application for employment or volunteer agreement;

(3)

verification of license, permits, reference(s), job experience, and educational requirements as appropriate; and

(4)

performance evaluations and disciplinary actions.

(b)

Original personnel files may be kept in any location as determined by the agency. Original personnel files must be accessible and readily retrievable for inspection by the department at the site of the survey.

§97.247.Criminal History Checks for Unlicensed Personnel.

(a)

An agency must comply with the Health and Safety Code, Chapter 250, Nurse Aide Registry and Criminal History Checks of Employees and Applicants for Employment in Certain Facilities Serving the Elderly or Persons with Disabilities. Failure to comply will be grounds for denial, suspension, or revocation of the agency's license in accordance with §97.601 of this title (relating to License Denial, Suspension, and Revocation).

(b)

An agency may not employ a person in a position, the duties of which involve direct contact with a consumer, unless the agency has applied for a criminal history check on the applicant for employment and unless there is an emergency.

(1)

An agency or a private entity working with the agency may submit a request for a criminal history check to the Texas Department of Human Services (DHS).

(2)

An agency may have a request submitted to the Texas Department of Public Safety (DPS) by a private entity working with the agency, instead of submitting the request to DHS.

(3)

If a private entity is used, it must submit requests in a timely manner.

(4)

If the agency is a parent agency, the parent agency must submit a request for a criminal history check on behalf of a branch office or alternate delivery site.

(5)

The requirement to request a criminal history check only applies if the person to be employed will have direct contact with a client of the agency.

(6)

A criminal history check is not required if the applicant for employment is licensed under Texas law and will be working within the scope of that license.

(7)

Criminal history checks may be requested only for applicants for employment to whom an offer of employment is made or, in the case of an agency's change of ownership, current agency employees. Criminal history checks may not be requested for persons who will not be employed by the agency, such as volunteers or independent contractors. An employee or applicant for employment is a person for whom the agency is or will be required to issue a W-2 form on behalf of the person.

(8)

A previous criminal history check on the person done under this section or through other means does not satisfy the requirements of the law or this section. A new criminal history check must be requested for any person each time an offer of employment is made to that person or for any person employed by an agency undergoing a change of ownership.

(c)

An agency may employ an applicant in an emergency requiring immediate employment under the following circumstances.

(1)

An emergency requiring immediate employment is a situation in which the urgent need to hire an individual exists as a result of a survey deficiency on staffing or the potential of the facility to fall below its desired staff, thus putting a client's health and safety at risk.

(2)

The prospective employee must furnish to the agency a written statement stating that he or she has no conviction for an offense described in the Health and Safety Code, §250.006, which lists the types of offenses which bar employment.

(3)

The written statements must be maintained in the agency personnel records.

(4)

The agency or a private entity working with the agency must request the criminal history check within 72 hours of employment for a person employed in an emergency situation.

(d)

If an agency is not having the requests submitted directly to the DPS by a private entity working with the agency, an agency must file a request for a criminal history check on official DHS forms. The requests must be forwarded to the designated representative of DHS. The request must be completely filled out including the mailing address, other names or alias(es), date of birth, race, and sex of the applicant or employee.

(e)

An agency must inform each person that applies for employment that the agency is required to conduct a criminal history check prior to making an offer of employment to the applicant (except in an emergency) and that the agency will request a criminal history check on each applicant to whom an offer of employment is made.

(f)

Convictions which are not reflected on the criminal history received from DPS do not trigger the requirements of this section or the Health and Safety Code, Chapter 250.

(g)

If DHS receives a criminal history from DPS, DHS will notify the agency requesting the check of the results. Criminal histories for employees of or applicants for employment to a branch office or alternate delivery site will be sent to the parent agency. The parent agency must notify the branch office or alternate delivery site of the findings.

(h)

The agency must inform the person how corrections to the criminal history may be made by contacting DPS.

(1)

Such corrections may include updating or making accurate the conviction information or clarifying that the conviction is actually the conviction of another person.

(2)

DHS will not provide assistance in correcting a criminal history.

(3)

It is the responsibility of the applicant for employment or the employee to correct errors of fact or identity in the criminal history received from DPS. The individual should contact DPS directly and provide whatever positive identification information may be required for a verification of the record and request a corrected criminal history.

(i)

The special provisions of the Health and Safety Code, Chapter 250, concerning nurse aides and the nurse aide registry, do not apply to persons hired as home health aides.

(j)

An agency must immediately discharge any employee in a position the duties of which involve direct contact with a client if the criminal history reveals a conviction of a crime listed in the Health and Safety Code, §250.006, that bars employment.

(k)

It is not necessary for the agency to notify DHS of any actions taken in response to the results of the criminal history on any individual.

(l)

The criminal history records and the information they contain may not be released or otherwise disclosed to any person or entity other than the subject of the information, except on court order or with the written consent of the person being investigated.

(1)

An agency may not share information with another agency or other providers except with the written consent of the person who is the subject of the criminal history check.

(2)

It is a criminal offense to release information in violation of the law.

§97.248.Volunteers.

(a)

This section applies to all licensed agencies. However, agencies licensed and certified to provide hospice services must also comply with 42 Code of Federal Regulations, Part 418.70, Medicare Conditions of Participation, relating to Volunteers.

(b)

If an agency utilizes volunteers, the agency must use volunteers in defined roles under the supervision of a designated agency employee.

(1)

A volunteer must meet the same requirements and standards in this chapter as apply to an employee of the agency doing the same activities unless the volunteer is exempt under this chapter from certain requirements or standards.

(2)

Volunteers may be used in administrative and direct client care roles.

(3)

The agency must document the level of volunteer activity.

(4)

The agency must record expansion of care and services achieved through the use of volunteers, including type of services and the time worked.

§97.249.Reports of Abuse, Neglect, and Exploitation.

An agency must adopt and enforce a written policy relating to the reporting of abuse, neglect or exploitation of clients.

(1)

In this section, "abuse," "exploitation," and "neglect" have the meanings assigned by §48.002, Human Resources Code.

(2)

An agency that has cause to believe that a client has been abused, exploited, or neglected by an employee of the agency must report the information upon discovery to:

(A)

the Texas Department of Human Services at 1-800-228-1570; and

(B)

the Texas Department of Protective and Regulatory Services at 1- 800-252-5400.

§97.250.Complaint Investigation.

(a)

An agency must adopt and enforce a written policy relating to the agency's procedures for investigating complaints. Such procedures must require the agency to:

(1)

investigate complaints made by a client or the client's family or guardian or the client's health care provider regarding treatment or care that is (or fails to be) furnished or regarding the lack of respect for the client's property by anyone furnishing services on behalf of the agency;

(2)

document the receipt of the complaint and initiate a complaint investigation within 10 calendar days of the agency's receipt of the complaint;

(3)

document all components of the investigation; and

(4)

complete the investigation and documentation within 30 calendar days after the agency receives the complaint, unless the agency has and documents reasonable cause for a delay.

(b)

An agency may not retaliate against a person for filing a complaint, presenting a grievance, or providing in good faith information relating to home health, hospice or personal assistance services provided by the agency.

(c)

An agency is not prohibited from terminating an employee for a reason other than retaliation.

§97.251.Peer Review.

An agency must adopt and enforce a written policy to ensure that all professional disciplines comply with their respective professional practice acts or title acts relating to reporting and peer review.

§97.252.Financial Solvency and Business Records.

An agency must have the financial ability to carry out its functions.

(1)

An agency must not intentionally or knowingly pay employees with checks from accounts with insufficient funds.

(2)

An agency must have sufficient funds to meet its payroll.

(3)

The agency must make available to the Texas Department of Human Services (DHS) upon request business records relating to its ability to carry out its functions. If there is a question relating to the accuracy of the records or the agency's financial ability to carry out its functions, DHS or its designee may conduct a more extensive review of the records. Any financial review by DHS will be conducted by an individual who has the financial qualifications to review such records.

(4)

An agency must maintain business records in their original state. Each entry must be accurate and dated with the date of entry. Correction fluid or tape may not be used in the record. Corrections must be made in accordance with standard accounting practices.

§97.253.Disclosure of Drug Testing Policy.

(a)

An agency that conducts drug testing of its employees must adopt and enforce a written policy governing drug testing of its employees.

(b)

An agency must provide a written statement describing the agency's policy for the drug testing of employees who have direct contact with clients to the following persons:

(1)

each person applying for services from the agency; and

(2)

any person requesting the information.

§97.254.Billing and Insurance Claims.

The agency must adopt and enforce a written policy to ensure that the agency submits accurate billings and insurance claims.

§97.255.Prohibition of Solicitation of Patients.

The agency must adopt and enforce a written policy to ensure compliance of the agency and its employees and contractors with the Occupations Code, Chapter 102 (concerning the Solicitation of Patients). For the purpose of this section a patient is considered to be a client.

§97.256.Natural Disaster Preparedness.

The agency must adopt and enforce a written policy that includes a plan for publicly known natural disaster preparedness for clients receiving services. The written policy must include a plan for the reasonable mechanism for triaging clients, the notification of appropriate personnel and clients in the event of a disaster if possible, the identification of appropriate community resources, and the identification of possible evacuation procedures. The plan need not require that the agency actually evacuate, transport, or triage the clients.

§97.257.Medicare Certification Optional.

(a)

An agency which makes application for licensed and certified home health category of service must comply with the regulations in the Medicare Conditions of Participation for Home Health Agencies, 42 Code of Federal Regulations (CFR), Part 484, pending approval of certification granted by the Health Care Financing Administration (HCFA). An agency providing hospice services and applying for participation in the Medicare program must comply with the Medicare Conditions of Participation for Hospice Services, 42 CFR, Part 418.

(b)

Upon the Texas Department of Human Services' (DHS's) receipt of written approval from HCFA, DHS will amend the licensing status of the agency to include the licensed and certified home health services category. The agency must then comply with §97.402 of this title (relating to Standards Specific to Licensed and Certified Home Health Services).

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102156

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


4. PROVISION AND COORDINATION OF TREATMENT AND SERVICES

40 TAC §§97.281 - 97.303

The new sections are proposed under the Health and Safety Code, Chapter 142, which provides the department with the authority to adopt rules for the licensing and regulation of home and community support services agencies.

The new sections implement the Health and Safety Code, Chapter 142.001-142.030.

§97.281.Client Care Policies.

The agency must adopt and enforce a written policy that specifies the agency's client care policies, which may include, as appropriate, clinical procedures, client rights, transfer and discharge procedures.

§97.282.Client Rights.

An agency must adopt and enforce a written policy governing client conduct and responsibility and client rights in accordance with this section.

(1)

In advance of furnishing care to the client or during the initial evaluation visit before the initiation of treatment, the agency must provide each client or their legal representative with a written notice of all rules and regulations governing client conduct and responsibility and client rights.

(2)

The client has the right to be informed in advance about the care to be furnished, the plan of care, expected outcomes, barriers to treatment and of any changes in the care to be furnished. The agency must ensure that an informed consent form that specifies the type of care and services that may be provided by the agency during the course of the illness has been obtained for every client, either from the client or their legal representative. The client or the legal representative must sign or mark the consent form.

(3)

The client has the right to participate in the planning of the care or treatment and in planning changes in the care or treatment.

(A)

The agency must advise or consult with the client or legal representative in advance of any change in the plan of care.

(B)

The client has the right to refuse care and services.

(C)

The client has the right to be informed, before care is initiated, of the extent to which payment may be expected from the client, third-party payors, and any other source of funding known to the agency.

(4)

The agency must protect and promote a client's rights.

(5)

A client has the right to have assistance in understanding and exercising his or her rights. The agency must maintain documentation showing that it has complied with the requirements of this paragraph and that the client demonstrates understanding of their rights.

(6)

The client has the right to exercise his or her rights as a client of the agency.

(7)

In the case of a client adjudged incompetent, the rights of the client are exercised by the person appointed by law to act on the client's behalf.

(8)

In the case of a client who has not been adjudged incompetent, any legal representative may exercise the client's rights to the extent permitted by law.

(9)

The client has the right to have his or her person and property treated with consideration, respect, and full recognition of his or her individuality and personal needs.

(10)

The client has the right to confidential treatment of his or her personal and medical records.

(11)

The client has the right to voice grievances regarding treatment or care that is or fails to be furnished, or regarding the lack of respect for property by anyone who is furnishing services on behalf of the agency and must not be subjected to discrimination or reprisal for doing so. There must be a written grievance mechanism under which a client can participate without fear of reprisal.

(12)

An agency must comply with the provisions of the Human Resources Code, Chapter 102, concerning the rights of the elderly.

§97.283.Advance Directives.

(a)

An agency must maintain a written policy regarding implementation of advance directives. The policy must be in compliance with the Advance Directives Act, Health and Safety Code, Chapter 166.

(1)

The policy must include a clear and precise statement of any procedure the agency is unwilling or unable to provide or withhold in accordance with an advance directive.

(2)

Except as provided by paragraph (4) of this subsection, the agency must provide written notice to an individual of the written policy required by this subsection. The notice must be provided at the earlier of:

(A)

the time the individual is admitted to receive services from the agency; or

(B)

the time the agency begins providing care to the individual.

(3)

If, at the time notice is to be provided under paragraph (2) of this subsection, the individual is incompetent or otherwise incapacitated and unable to receive the notice required by this subsection, the agency must provide the required written notice, in the following order of preference, to:

(A)

the individual's legal guardian;

(B)

a person responsible for the health care decisions of the individual;

(C)

the individual's spouse;

(D)

the individual's adult child;

(E)

the individual's parent; or

(F)

the person admitting the individual.

(4)

If paragraph (3) of this subsection applies and except as provided by paragraph (5) of this subsection, if an agency is unable, after diligent search, to locate an individual listed by paragraph (3) of this subsection, the agency is not required to provide the notice.

(5)

If an individual who was incompetent or otherwise incapacitated and unable to receive the notice required by this subsection at the time notice was to be provided under paragraph (2) of this subsection later becomes able to receive the notice, the agency must provide the written notice at the time the individual becomes able to receive the notice.

(b)

The Texas Department of Human Services (DHS) will assess an administrative penalty of $500 against an agency that violates subsection (a) of this section, relating to requirements for the provision of a written statement relating to advance directives. DHS will provide notice of administrative penalty and opportunity for a hearing in accordance with §97.602 of this title (relating to Administrative Penalties).

§97.284.Laboratory Services.

An agency that provides laboratory services must adopt, and enforce a written policy to ensure that the agency meets the Clinical Laboratory Improvement Act, 42 United States Code Annotated, §263a, (CLIA 1988). CLIA 1988 applies to all agencies with laboratories that examine human specimens for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings.

§97.285.Infection Control.

An agency must adopt and enforce written policies addressing infection control including the prevention of the spread of infectious and communicable disease. The policies must:

(1)

ensure compliance with the Communicable Disease Prevention and Control Act, Health and Safety Code, Chapter 81;

(2)

ensure compliance with Occupational Safety and Health Administration (OSHA), 29 CFR Part 1910.1030 relating to Bloodborne Pathogens and Appendix A to 1910.1030;

(3)

require documentation of infections that are acquired while the client is receiving services from the agency. Documentation must include at a minimum the date that the infection was determined to be present, the client's name, primary diagnosis, signs/symptoms, type of infection, pathogens identified and treatment; and

(4)

ensure compliance of the agency and its employees and contractors with the Health and Safety Code, Chapter 85, Subchapter I, concerning the prevention of the transmission of human immunodeficiency virus and hepatitis B virus.

§97.286.Disposal of Special or Medical Waste.

(a)

An agency must adopt and enforce a written policy for the safe handling and disposal of biohazardous waste and materials, if applicable.

(b)

An agency that generates special or medical waste while providing home health services must dispose of the waste according to the requirements in 25 TAC, §§1.131-1.137 (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities). An agency must provide both verbal and written instructions to the agency's clients regarding the proper procedure for disposing of sharps. For purposes of this subsection, sharps include hypodermic needles, hypodermic syringes with attached needles, scalpel blades, razor blades, disposable razors, disposable scissors used in medical procedures, and intravenous stylets and rigid introducers.

§97.287.Quality Assurance.

(a)

Quality Assurance (QA) Program.

(1)

An agency must maintain a QA Program that will be implemented by a QA Committee. The QA Program must be ongoing, focused on client outcomes that are measurable, and have a written plan of implementation. This plan must be reviewed and updated or revised at least once within a calendar year, or more often if needed, by the QA Committee. The QA Program must include:

(A)

a system of measures that captures significant outcomes that are essential to optimal care, are used in the care planning and coordination of services and events, and are an essential part of the agency's quality assessment and performance improvement program. The measures must include at a minimum:

(i)

an analysis of a representative sample of services furnished to clients contained in both active and closed records;

(ii)

a review of:

(I)

negative client care outcomes;

(II)

issues of unprofessional conduct by staff;

(III)

infection control activities; and

(IV)

medication errors;

(iii)

a determination that services have been performed as outlined in the service plan, care plan, or plan of care; and

(iv)

an analysis of client complaint and satisfaction survey data; and

(B)

an annual evaluation of the total operation, including services provided under contract or arrangement. The findings are to be used by the agency to correct identified problems and to revise policies, if necessary.

(2)

QA documents must be kept confidential and available to the Texas Department of Human Services (DHS) staff upon request.

(b)

QA Committee membership. At a minimum, the QA Committee must consist of at least:

(1)

the administrator;

(2)

the supervising nurse/therapist, or the supervisor of an agency licensed to provide personal assistance services (PAS) if delegating health related tasks; and

(3)

a representative from each skilled and unskilled discipline providing services.

(c)

Frequency of QA Committee meeting. The QA Committee must meet at least quarterly.

§97.288.Coordination of Services.

(a)

An agency must adopt and enforce a policy to require that all service providers involved in the care of a client, including contracted health care professionals or another agency, are engaged in an effective interchange, reporting, and coordination of care regarding the client.

(b)

The agency must document the steps taken to meet subsection (a) of this section in the client record.

§97.289.Independent Contractors and Arranged Services.

(a)

Independent contractors. If an agency uses independent contractors, there must be a contract between each independent contractor that performs services on a per-visit per-hour basis and the agency. The contract must be enforced by the agency and clearly designate:

(1)

that clients are accepted for care only by the licensed agency;

(2)

the services to be provided;

(3)

the necessity to conform to all applicable agency policies, including personnel qualifications;

(4)

the plan of care or care plan to be carried out;

(5)

the manner in which services will be coordinated and evaluated by the licensed agency in accordance with §97.288 of this title (relating to Coordination of Services);

(6)

the procedures for:

(A)

submitting information and documentation regarding the client's needs and services, including clinical and progress notes;

(B)

scheduling of visits;

(C)

periodic client evaluation or supervision; and

(D)

determining charges and reimbursement.

(b)

Arranged services. Services provided by an agency under arrangement with another agency or organization must be provided under written agreement conforming with the requirements specified in subsection (a) of this section.

§97.290.Backup Services and After Hours Care.

(a)

Backup services. An agency must adopt and enforce a written policy to ensure that back-up services are available when an employee or contractor is not able to deliver the services.

(b)

After hours care. An agency must adopt and enforce a policy to ensure that clients are educated in how to access care from another health care provider after regular business hours.

§97.291.Agency Dissolution.

An agency must adopt and enforce a written policy which describes the agency's written contingency plan.

(1)

The plan must be implemented in the event of dissolution to assure continuity of client care.

(2)

The plan must:

(A)

be consistent with §97.295 of this title (relating to Client Transfer or Discharge Notification Requirements);

(B)

include procedures for:

(i)

notifying the client of the agency's dissolution;

(ii)

documenting the notification;

(iii)

carrying out the notification; and

(C)

comply with §97.217(2) of this title (relating to Agency Closure Procedures).

§97.292.Agency and Client Agreement and Disclosure.

(a)

The agency must provide the client or the client's family with a written agreement for services. The agency must comply with the terms of the agreement. The agreement must include at a minimum the following:

(1)

notification of client rights;

(2)

documentation concerning notification to the client of the availability of durable power of attorney for health care, advance directive or "Do Not Resuscitate" orders in accordance with the applicable law;

(3)

services to be provided;

(4)

supervision by the agency of services provided;

(5)

agency charges for services rendered if the charges will be paid in full or in part by the client or the client's family, or on request;

(6)

agency's policy relating to the reporting of abuse, neglect or exploitation of a client; and

(7)

a client agreement to and acknowledgement of services by home health medication aides, if home health medication aides are used.

(b)

The agency must obtain an acknowledgment of receipt from the client or his family of the items listed under subsection (a) of this section. This acknowledgment of receipt must be kept in the client's record.

§97.293.Client List and Services.

An agency must maintain a current list of clients for each category of service licensed.

(1)

The list must include all services being delivered by the agency and services being delivered under contract.

(2)

The client list must include the client's name, identification or clinical record number, start of care date or admission date, certification period (if applicable), diagnosis(es), and the disciplines that are providing services.

§97.294.Time Frame(s) for the Initiation of Care or Services.

An agency must adopt and enforce a written policy establishing time frame(s) for the initiation of care or services.

§97.295.Client Transfer or Discharge Notification Requirements.

(a)

Except in an emergency, an agency intending to transfer or discharge a client must notify the client or the client's parent, family, spouse, significant other, or legal representative, and the client's attending physician (if applicable) not later than five days before the date on which the client will be transferred or discharged.

(b)

An agency may transfer or discharge a client without five days notice required by subsection (a) of this section:

(1)

upon the client's request;

(2)

if the client's medical needs require transfer, such as a medical emergency;

(3)

in the event of a natural disaster when the client's health and safety is at risk;

(4)

for the protection of staff or a client after the agency has made a documented reasonable effort to notify the client, the client's family and physician, and appropriate state or local authorities of the agency's concerns for staff or client safety, and in accordance with agency policy;

(5)

according to physician orders; or

(6)

if the client fails to pay for services, except as prohibited by federal law.

(c)

The agency must document notice required by subsection (a) of this section in the client's file.

§97.296.Physician Delegation and Performance of Physician-Delegated Tasks.

(a)

If performing physician delegation, an agency must adopt and enforce a written policy describing protocols and procedures agency staff must follow when performing physician-delegated tasks.

(1)

The policy must comply with the Medical Practice Act, Occupations Code, Chapter 157, concerning physician delegation.

(2)

The policy must address the time frame for the timely counter signature of a physician's verbal orders.

(b)

An agency may accept delegation from a physician only if the agency receives the following from the physician:

(1)

the name of the client;

(2)

the name of the delegating physician;

(3)

the task(s) to be performed;

(4)

the name of the individual(s) to perform the task(s);

(5)

the time frame for the delegation order; and

(6)

if the task is medication administration, the medication to be given, route, dose, and frequency.

§97.297.Receipt of Physician Orders.

An agency must adopt and enforce a written policy describing protocols and procedures agency staff must follow when receiving physician orders.

(1)

The policy must address the time frame for countersignature of physician verbal orders.

(2)

Signed physician orders may be submitted via facsimile machine. The agency is not required to have the original signatures on file. However, the agency must be able to obtain original signatures if an issue surfaces that would require verification of an original signature. The policy must include protocols to follow when accepting physician orders via facsimile. If physician orders are accepted via facsimile, the policy must:

(A)

outline safeguards to assure that transmitted information is sent to the appropriate individual; and

(B)

outline the procedures to be followed in the case of misdirected transmission.

§97.298.Delegation of Selected Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel.

An agency must adopt and enforce a written policy to ensure compliance with the rules of the Board of Nurse Examiners for the State of Texas adopted at 22 TAC Chapter 218 (Delegation of Selected Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel).

§97.299.Vocational Nursing Education, Licensure and Practice.

An agency must adopt and enforce a written policy to ensure compliance with the rules of the Board of Vocational Nurse Examiners adopted at 22 TAC Chapters 231-240 (relating to Vocational Nursing Education, Licensure and Practice in the State of Texas).

§97.300.Medication Administration.

An agency must adopt and enforce a written policy for maintaining a current medication list and medication administration record. Administration of medication must be ordered by the client's practitioner. A current medication list and medication administration records may be incorporated into one document. Notation must be made in the medication administration record or clinical notes of medications not given and the reason. Any adverse reaction must be reported to a supervisor and documented in the client record on the day of occurrence.

§97.301.Client Records.

(a)

In accordance with accepted principles of practice, an agency must establish and maintain a client record system to assure that the care and services provided to each client is completely and accurately documented, readily accessible and systematically organized to facilitate the compilation and retrieval of information.

(1)

An agency must establish a record for each client which is maintained in accordance with and contains the information described in paragraph (9) of this subsection. An agency must keep a single file or separate files for each category of service provided to the client and the client's family. Hospice services provided to a client's family must be documented in the clinical record.

(2)

The agency must adopt and enforce written procedures regarding the use and removal of records, the release of information, and when applicable, the incorporation of clinical, progress, or other notes into the client record. An agency may not release any portion of a client record to anyone other than the client except as allowed by law.

(3)

All information regarding the client's care and services must be centralized in the client's record and be protected against loss or damage.

(4)

The agency must establish an area for original active client record storage at the agency's place of business. The original active client record must be stored at the place of business (parent agency, branch office, or alternate delivery site) from which services are actually provided. Original active client records must not be stored at an administrative support site or records storage facility.

(5)

The agency must ensure that each client's record is treated with confidentiality, safeguarded against loss and unofficial use, and is maintained according to professional standards of practice.

(6)

The clinical record must be an original, a microfilmed copy, an optical disc imaging system, or a certified copy. An original record includes manually signed paper records or electronically signed computer records. Computerized records must meet all requirements of paper records including protection from unofficial use and retention for the period specified in subsection (b) of this paragraph. Systems must assure that entries regarding the delivery of care or services are not altered without evidence and explanation of such alteration.

(7)

Each entry to the client record must be current, accurate, signed, and dated with the date of entry by the individual making the entry. The record must include all services whether furnished directly or under arrangement. Correction fluid or tape must not be used in the record. Corrections must be made by striking through the error with a single line and must include the date the correction was made and the initials of the person making the correction.

(8)

Inactive client records may be preserved on microfilm, optical disc or other electronic means and may be stored at the parent agency location, branch office, alternate delivery site, administrative support site, or records storage facility. Security must be maintained and the record must be readily retrievable by the agency.

(9)

Each client record must include (as applicable):

(A)

client application for services including, but not limited to: full name; sex; date of birth; name, address, and telephone number of parent(s) of a minor child, or legal guardian, or other(s) as identified by the individual; physician's name and telephone numbers, including emergency numbers; and services requested;

(B)

initial health assessment, pertinent medical history, and subsequent health assessments;

(C)

care plan, plan of care, or individualized service plan, as applicable. The care plan or the plan of care must include, as applicable, medication, dietary, treatment, and activities orders. The requirements for the individualized service plan for personal assistance service clients are located in §97.404 of this title (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services). The requirements for the plan of care for hospice clients are located in §97.403 of this title (relating to Standards Specific to Agencies Licensed to Provide Hospice Services);

(D)

clinical and progress notes. Such notes are to be written the day service is rendered and incorporated into the client record within 14 days;

(E)

current medication list;

(F)

medication administration record (if medication is administered by agency staff). Notation must also be made in the medication administration record or in the clinical notes of medications not given and the reason. Any adverse reaction must be reported to a supervisor and documented in the client record;

(G)

records of supervisory visits;

(H)

complete documentation of all known services and significant events. Documentation must show that effective interchange, reporting, and coordination of care occurs as required in §97.288 of this title (relating to Coordination of Services);

(I)

for clients 60 years and older, acknowledgment of the client's receipt of a copy of the Human Resources Code, Chapter 102, Rights of the Elderly;

(J)

acknowledgment of the client's receipt of the agency's policy relating to the reporting of abuse, neglect, or exploitation of a client;

(K)

documentation that the client has received a copy of the agency's complaint procedures;

(L)

client agreement to and acknowledgment of services by home health medication aides, if home health medication aides are used;

(M)

discharge summary, including the reason for discharge or transfer and the agency's documented notice to the client, the client's physician (if applicable), and other individuals as required in §97.295 of this title (relating to Client Transfer or Discharge Notification Requirements);

(N)

acknowledgement of receipt of the notice of advance directives;

(O)

services provided to the client's family (as applicable); and

(P)

consent and authorization and election forms, as applicable.

(b)

An agency must adopt and enforce a written policy relating to the retention of records in accordance with this subsection.

(1)

An agency must retain original client records for a minimum of five years after the discharge of the client.

(2)

The agency may not destroy client records that relate to any matter that is involved in litigation if the agency knows the litigation has not been finally resolved.

(3)

There must be an arrangement for the preservation of inactive records to insure compliance with this subsection.

§97.302.Pronouncement of Death.

An agency must adopt and enforce a written policy on pronouncement of death if that function is carried out by an agency registered nurse. The policy must be in compliance with the Health and Safety Code, §671.001 (concerning Determination of Death and Autopsy Reports).

§97.303.Standards for Possession of Sterile Water or Saline, Certain Vaccines or Tuberculin, and Certain Dangerous Drugs.

An agency which possesses sterile water or saline, certain vaccines or tuberculin, or certain dangerous drugs as specified by this section, must comply with the provisions of this section.

(1)

Possession of sterile water or saline. An agency or its employees who are registered nurses or licensed vocational nurses may purchase, store, or transport for the purpose of administering to their home health or hospice clients under physician's orders:

(A)

sterile water for injection and irrigation; and

(B)

sterile saline for injection and irrigation.

(2)

Possession of certain vaccines or tuberculin.

(A)

An agency or its employees who are registered nurses or licensed vocational nurses may purchase, store, or transport for the purpose of administering to the agency's employees, home health, or hospice clients, or client family members under physician's standing orders the following dangerous drugs:

(i)

hepatitis B vaccine;

(ii)

influenza vaccine; and

(iii)

tuberculin purified protein derivative for tuberculosis testing.

(B)

An agency that purchases, stores, or transports a vaccine or tuberculin under this section must ensure that any standing order for the vaccine or tuberculin:

(i)

is signed and dated by the physician;

(ii)

identifies the vaccine or tuberculin covered by the order;

(iii)

indicates that the recipient of the vaccine or tuberculin has been assessed as an appropriate candidate to receive the vaccine or tuberculin and has been assessed for the absence of any contraindication;

(iv)

indicates that appropriate procedures are established for responding to any negative reaction to the vaccine or tuberculin; and

(v)

orders that a specific medication or category of medication be administered if the recipient has a negative reaction to the vaccine or tuberculin.

(3)

Possession of certain dangerous drugs.

(A)

In compliance with Health and Safety Code, §142.0063, an agency or its employees who are registered nurses or licensed vocational nurses may purchase, store, or transport for the purpose of administering to their home health or hospice patients, in accordance with subparagraph (C) of this paragraph, the following dangerous drugs:

(i)

any of the following items in a sealed portable container of a size determined by the dispensing pharmacist:

(I)

1,000 milliliters of 0.9% sodium chloride intravenous infusion;

(II)

1,000 milliliters of 5.0% dextrose in water injection; or

(III)

sterile saline; or

(ii)

not more than five dosage units of any of the following items in an individually sealed, unused portable container:

(I)

heparin sodium lock flush in a concentration of 10 units per milliliter or 100 units per milliliter;

(II)

epinephrine HCI solution in a concentration of one to 1,000;

(III)

diphenhydramine HCI solution in a concentration of 50 milligrams per milliliter;

(IV)

methylprednisolone in a concentration of 125 milligrams per two milliliters;

(V)

naloxone in a concentration of one milligram per milliliter in a two-milliliter vial;

(VI)

promethazine in a concentration of 25 milligrams per milliliter;

(VII)

glucagon in a concentration of one milligram per milliliter;

(VIII)

furosemide in a concentration of 10 milligrams per milliliter;

(IX)

lidocaine 2.5% and prilocaine 2.5% cream in a five-gram tube; or

(X)

lidocaine HCL solution in a concentration of 1% in a two-milliliter vial.

(B)

An agency or the agency's authorized employees may purchase, store, or transport dangerous drugs in a sealed portable container only if the agency has established policies and procedures to ensure that:

(i)

the container is handled properly with respect to storage, transportation, and temperature stability;

(ii)

a drug is removed from the container only on a physician's written or oral order;

(iii)

the administration of any drug in the container is performed in accordance with a specific treatment protocol; and

(iv)

the agency maintains a written record of the dates and times the container is in the possession of a registered nurse or licensed vocational nurse.

(C)

An agency or the agency's authorized employee who administers a drug listed in subparagraph (A) of this paragraph may administer the drug only in the client's residence under physician's orders in connection with the provision of emergency treatment or the adjustment of:

(i)

parenteral drug therapy; or

(ii)

vaccine or tuberculin administration.

(D)

If an agency or the agency's authorized employee administers a drug listed in subparagraph (A) of this paragraph pursuant to a physician's oral order, the agency must receive a signed copy of the order:

(i)

not later than 24 hours after receipt of the order, reduce the order to written form and send a copy of the form to the dispensing pharmacy by mail or facsimile transmission; and

(ii)

not later than 20 days after receipt of the order, send a copy of the order as signed by and received from the physician to the dispensing pharmacy.

(E)

A pharmacist that dispenses a sealed portable container under this subsection will ensure that the container:

(i)

is designed to allow access to the contents of the container only if a tamper-proof seal is broken;

(ii)

bears a label that lists the drugs in the container and provides notice of the container's expiration date, which is the earlier of:

(I)

the date that is six months after the date on which the container is dispensed; or

(II)

the earliest expiration date of any drug in the container; and

(iii)

remains in the pharmacy or under the control of a pharmacist, registered nurse, or licensed vocational nurse.

(F)

If an agency or the agency's authorized employee purchases, stores, or transports a sealed portable container under this subsection, the agency must deliver the container to the dispensing pharmacy for verification of drug quality, quantity, integrity, and expiration dates not later than the earlier of:

(i)

the seventh day after the date on which the seal on the container is broken; or

(ii)

the date for which notice is provided on the container label.

(G)

A pharmacy that dispenses a sealed portable container under this section is required to take reasonable precautionary measures to ensure that the agency receiving the container complies with subparagraph (F) of this paragraph. On receipt of a container under subparagraph (F) of this paragraph, the pharmacy will perform an inventory of the drugs used from the container and will restock and reseal the container before delivering the container to the agency for reuse.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102157

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


5. BRANCH OFFICES AND ALTERNATE DELIVERY SITES

40 TAC §97.321, §97.322

The new sections are proposed under the Health and Safety Code, Chapter 142, which provides the department with the authority to adopt rules for the licensing and regulation of home and community support services agencies.

The new sections implement the Health and Safety Code, Chapter 142.001-142.030.

§97.321.Standards for Branch Offices.

(a)

A parent agency is eligible to apply for a branch office license:

(1)

if the agency has successfully completed an initial onsite survey; or for an agency with a first renewal or subsequent renewal license, if the agency continues to demonstrate substantial compliance with the statute and this chapter; and

(2)

if enforcement action against the agency license is not proposed under Subchapter F of this chapter (relating to Enforcement).

(b)

A branch office providing licensed home health or personal assistance services must comply with the same rules that apply to the parent agency and the standards specific to the licensed category(ies) of service(s).

(c)

A branch office providing licensed and certified home health services must comply with the standards for certified agencies in §97.402 of this title (relating to Standards Specific to Licensed and Certified Home Health Services).

(d)

A branch office must establish a service area within the parent agency's service area.

(1)

A branch office must provide services only within its established service area.

(2)

The branch office must maintain adequate staff to provide services and to supervise the provision of services within the service area.

(3)

A branch office may expand its service area at any time during the licensure period.

(A)

Unless exempted under subparagraph (B) of the paragraph, to expand its service area, a branch office must submit to the Texas Department of Human Services (DHS) a written notice 30 days prior to the expansion which includes:

(i)

revised boundaries of the branch office's original service area;

(ii)

the effective date of the expansion; and

(iii)

an updated list of management and supervisory personnel (including names), if changes are made.

(B)

An agency will be exempted from the 30-day written notice requirement under subparagraph (A) of this paragraph if DHS determines an emergency exists that would adversely impact client health and safety. An agency must notify DHS immediately of a possible emergency. DHS will determine if an exemption will be granted.

(4)

A branch office may reduce its service area at any time during the licensure period by sending DHS written notification of the reduction, revised boundaries of the branch office's original service area, and the effective date of the reduction.

(e)

A parent agency and a branch office providing home health or personal assistance services must meet the following requirements.

(1)

On-site supervision of the branch office must be conducted at least monthly by the parent agency administrator, administrator's designee, or supervising nurse or designee. More frequent supervision may be required considering the size of the service area and the scope of services provided by the parent agency. The supervisory visits must be documented and include the date of the visit, the content of the consultation, the individuals in attendance, and the recommendations of the staff.

(2)

The original active clinical record must be kept at the branch office.

(3)

The parent agency must approve all branch office policies and procedures. Such approval must be documented and filed in the parent and branch offices.

(f)

DHS will issue or renew a branch office license for applicants who meet the requirements of this section.

(1)

Issuance or renewal of a branch office license is contingent upon compliance with the statute and this chapter by the parent agency and branch office.

(2)

DHS may take enforcement action against a parent agency license for a branch office's failure to comply with the statute or this chapter. Enforcement action will be in accordance with Subchapter F of this chapter (relating to Enforcement).

(3)

Revocation, suspension, denial, or surrender of a parent agency license will result in the same revocation, suspension, denial, or surrender of a branch office license for all branch office licenses of the parent agency.

(g)

A branch office may offer fewer health services or categories than the parent office but may not offer health services or categories that are not also offered by the parent agency.

§97.322.Standards for Alternate Delivery Sites.

(a)

A hospice is eligible to apply for an alternate delivery site license:

(1)

if the agency has successfully completed an initial onsite survey; or for a hospice agency with a first renewal or subsequent renewal license, if the agency continues to demonstrate substantial compliance with the statute and this chapter; and

(2)

if enforcement action against the agency is not proposed under Subchapter F of this chapter (relating to Enforcement).

(b)

An alternate delivery site providing hospice services must comply with §97.403 of this title (relating to Standards Specific to Agencies Licensed to Provide Hospice Services).

(c)

An alternate delivery site must independently meet §97.403(c), (f) (1), and (i) of this title (relating to Standards Specific to Agencies Licensed to Provide Hospice Services), and §97.301 of this title (relating to Client Records).

(d)

An alternate delivery site must be established within the parent hospice's service area.

(1)

The alternate delivery site must provide services only within its established service area.

(2)

The alternate delivery site must maintain adequate staff to provide services and to supervise the provision of services within the service area.

(3)

An alternate delivery site may expand its service area at any time during the licensure period.

(A)

Unless exempted under subparagraph (B) of this paragraph, to expand its service area, an alternate delivery site must submit to the Texas Department of Human Services (DHS) a written notice 30 days prior to the expansion which includes:

(i)

revised boundaries of the alternate delivery site's original service area;

(ii)

the effective date of the expansion; and

(iii)

an updated list of management and supervisory personnel (including names), if changes are made.

(B)

An agency will be exempted from the 30-day written notice requirement under subparagraph (A) of this paragraph if DHS determines that an emergency exists that would impact client health and safety. An agency must notify DHS immediately of a possible emergency. DHS will determine if an exemption can be granted.

(4)

An alternate delivery site may reduce its service area at any time during the licensure period by sending DHS written notification of the reduction, revised boundaries of the alternate delivery site's original service area, and the effective date of the reduction.

(e)

A hospice and an alternate delivery site providing hospice services must meet the following requirements.

(1)

On-site supervision of the alternate delivery site must be conducted by the parent agency at least monthly. More frequent supervision may be required considering the size of the service area provided by the parent agency. The parent agency administrator, administrator's designee, or supervising nurse or designee must conduct supervisory visits to the alternate delivery site. The supervisory visits must be documented and include the date of the visit, the content of the consultation, the individuals in attendance, and the recommendations of the staff.

(2)

The original active clinical record must be kept at the alternate delivery site office.

(3)

The parent agency must approve all alternate delivery site policies and procedures. Such approval must be documented and filed in the parent and alternate delivery sites.

(f)

DHS will issue to or renew an alternate delivery site license for applicants who meet the requirements of this section.

(1)

Issuance or renewal of an alternate delivery site office license is contingent upon compliance with the statute and this chapter by the parent agency and alternate delivery site.

(2)

DHS may take enforcement action against a parent agency license for an alternate delivery site's failure to comply with the statute or this chapter. Enforcement action will be in accordance with Subchapter F of this chapter (relating to Enforcement).

(3)

Revocation, suspension, denial or surrender of a parent agency license will result in the same revocation, suspension, denial or surrender of all alternate delivery site licenses of the parent agency.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102158

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


Subchapter D. ADDITIONAL STANDARDS SPECIFIC TO LICENSE CATEGORY AND SPECIFIC TO SPECIAL SERVICES

40 TAC §§97.401 - 97.407

The new sections are proposed under the Health and Safety Code, Chapter 142, which provides the department with the authority to adopt rules for the licensing and regulation of home and community support services agencies.

The new sections implement the Health and Safety Code, Chapter 142.001-142.030.

§97.401.Standards Specific to Licensed Home Health Services.

(a)

In addition to the standards in Subchapter C of this chapter (relating to Minimum Standards for All Licensed Home and Community Support Services Agencies), an agency providing licensed home health services must also meet the standards of this section.

(b)

The agency must accept a client for home health services on the basis of a reasonable expectation that the client's medical, nursing, and social needs can be met adequately in the client's residence. An agency has made a reasonable expectation that it can meet a client's needs if, at the time of the agency's acceptance of the client, the client and the agency have agreed as to what needs the agency would meet; for instance, the agency and the client could agree that some needs would be met but not necessarily all needs.

(1)

The agency must start providing licensed home health services to a client within a reasonable time after acceptance of the client and according to the agency's policy. The initiation of licensed home health services must be based on the client's health service needs.

(2)

An initial health assessment must be performed in the client's residence by the appropriate health care professional prior to or at the time that licensed home health services are initially provided to the client. The assessment must determine whether the agency has the ability to provide the necessary services.

(A)

If a practitioner has not ordered skilled care for a client, then the appropriate health care professional must prepare a care plan. The care plan must be developed after consultation with the client and the client's family and must include services to be rendered, the frequency of visits or hours of service, identified problems, method of intervention, and projected date of resolution. The care plan must be reviewed and updated by all appropriate staff members involved in client care at least annually, or more often as necessary to meet the needs of the client.

(B)

If a practitioner orders skilled treatment, then the appropriate health care professional must prepare a plan of care. The plan of care must be signed and approved by a practitioner in a timely manner. The plan of care must be developed in conjunction with agency staff and must cover all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits at the time of admission, prognoses, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, and any other appropriate items. The appropriate health care personnel must perform services as specified in the plan of care. The plan of care must be revised as necessary, but it must be reviewed and updated at least every six months.

(c)

Agency staff must provide at least one home health service. All services must be rendered and supervised by qualified personnel. The appropriate health professional must be available to supervise as needed, when services are provided.

(1)

If nursing service is provided, a registered nurse must be employed by or be under contract with the agency to provide services or supervision.

(2)

If physical therapy service is provided, a physical therapist must be employed by or be under contract with the agency to provide services or supervision.

(3)

If occupational therapy service is provided, an occupational therapist must be employed by or be under contract with the agency to provide services or supervision.

(4)

If speech-language pathology services are provided, a speech-language pathologist must be employed by or be under contract with the agency to provide services or supervision.

(5)

If audiology services are provided, an audiologist must be employed by or be under contract with the agency to provide services or supervision.

(6)

If medical social service is provided, a social worker with a bachelor's degree in social work from an accredited college or university must be employed by or be under contract with the agency to provide services or supervision. When medical social service is provided in an agency with a home dialysis designation, the social worker must meet the qualifications in §97.405(q) of this title (relating to Standards Specific to Agencies Licensed to Provide Home Dialysis Services).

(7)

If nutritional counseling is provided, a dietitian or registered nurse must be employed by or be under contract with the agency to provide services or supervision.

(8)

If services are provided by unlicensed personnel, a qualified person must be employed by or be under contract with the agency to provide the service and a registered nurse must be employed by or be under contract with the agency to perform the initial health assessment, prepare the client care plan, as appropriate, and supervise the unlicensed personnel.

(9)

If respiratory therapy service is provided, a respiratory therapist must be employed by or be under contract with the agency to provide services.

(d)

An agency may use a home health aide who meets the qualifications in §97.701 of this title (relating to Home Health Aides) or other individuals under the supervision of a registered nurse or physician. This subsection applies only to an agency providing licensed home health services that implements a home health aide training and competency evaluation program.

(1)

An agency providing licensed home health services is not required to utilize home health aides. Unlicensed personnel utilized by an agency providing licensed home health services must be at least 18 years of age and must demonstrate competency in the task assigned when competency can not be determined through education and experience. An unlicensed person who is under 18 years of age, is a high school graduate or is enrolled in a vocational educational program, and has demonstrated competency to perform the tasks assigned by the supervisor, may perform licensed home health services.

(2)

An agency providing licensed home health services that implements a home health aide training and competency evaluation program must meet the requirements in §97.701(d)-(f) of this title (relating to Home Health Aides).

(3)

An agency providing licensed home health services that implements a home health aide competency evaluation program must comply with §97.701(f) of this title (relating to Home Health Aides).

(4)

Since the individual's most recent completion of a training and competency evaluation program or a competency evaluation program, if there has been a period of 24 consecutive months during which the individual has not furnished home health services, the individual will not be considered as having completed a training and competency evaluation program or a competency evaluation program.

§97.402.Standards Specific to Licensed and Certified Home Health Services.

(a)

In addition to the standards in Subchapter C of this chapter (relating to Minimum Standards for All Licensed Home and Community Support Services Agencies), an agency providing licensed and certified home health services must comply with the requirements of the Social Security Act and the regulations in Title 42 of the Code of Federal Regulations, Part 484. Copies of the regulations adopted by reference in this section are indexed and filed in the Texas Department of Human Services, 701 W. 51st Street, Austin, Texas 78756, and are available for public inspection during regular working hours.

(b)

An agency providing licensed and certified home health services that plans to implement a home health aide training and competency evaluation program must meet the requirements in §97.701(d)-(f) of this title (relating to Home Health Aides).

(c)

An agency providing licensed and certified home health services that plans to implement a competency evaluation program must comply with §97.701(f) of this title (relating to Home Health Aides).

(d)

An agency providing licensed and certified home health services may not use an individual as a home health aide unless:

(1)

the individual has met the federal requirements under subsection (a) of this section;

(2)

the individual qualifies as a home health aide on the basis of a:

(A)

training and competency evaluation program, and the program meets the requirements of subsection (b) of this section; or

(B)

competency evaluation program, and the program meets the requirements of subsection (c) of this section; or

(3)

the individual is a licensed health care provider.

(e)

Since the individual's most recent completion of a training and competency evaluation program or a competency evaluation program, if there has been a period of 24 consecutive months during which the individual has not furnished home health services, the individual will not be considered as having completed a training and competency evaluation program or a competency evaluation program.

§97.403.Standards Specific to Agencies Licensed to Provide Hospice Services.

(a)

In addition to complying with the minimum standards in Subchapter C of this chapter (relating to Minimum Standards for All Home and Community Support Services Agencies), an agency that is licensed to provide hospice services, must also comply with the standards of this section. If licensed and certified to provide hospice services, an agency must also comply with the requirements of the Social Security Act and the regulations in Title 42, Code of Federal Regulations, Part 418.

(b)

A person who is not licensed to provide hospice services may not use the word "hospice" in a title or description of a facility, organization, program, service provider or services or use any other words, letters, abbreviations, or insignia indicating or implying that the person holds a license to provide hospice services.

(c)

A hospice must adopt and enforce a written policy relating to the provision of hospice services in accordance with this section. All covered services must be available 24 hours a day, seven days a week, during the last stages of illness, during death, and during bereavement, to the extent necessary for the palliation and management of terminal illness and related conditions. Services include, at a minimum:

(1)

nursing;

(2)

medical social services;

(3)

counseling;

(4)

volunteer care;

(5)

bereavement counseling;

(6)

coordination of short-term inpatient care;

(7)

physician services; and

(8)

medications.

(d)

The hospice must have a medical director who:

(1)

is a hospice employee, independent contractor, or volunteer;

(2)

is a doctor of medicine or osteopathy licensed in the State of Texas; and

(3)

assumes responsibility for the medical component of the hospice's client care program.

(e)

The hospice must designate an interdisciplinary team or teams composed of individuals who provide or supervise the care and services offered by the hospice.

(1)

The interdisciplinary team or teams must include at least the following individuals who are employees of the hospice:

(A)

a physician;

(B)

a registered nurse;

(C)

a social worker; and

(D)

a counselor.

(2)

The interdisciplinary team must be responsible for:

(A)

participation in the establishment of the plan of care;

(B)

provision and supervision of hospice care and services;

(C)

periodic reviews and updates of the plan of care for each client receiving hospice care; and

(D)

establishment of policies governing the day to day provision of hospice care and services.

(3)

If the hospice has more than one interdisciplinary team, the hospice must designate in advance the team it chooses to execute the functions described in paragraph (2)(D) of this subsection.

(4)

The hospice must designate a registered nurse to coordinate the implementation of the plan of care for each client.

(f)

Subject to subsections (m ) and (r) of this section, the hospice may arrange for another individual or entity to furnish services to the hospice clients. If services are provided under arrangement, the hospice must meet the following standards.

(1)

The hospice program must assure the continuity of client and family care in home and outpatient and inpatient settings.

(2)

The hospice must have a contract for the provision of arranged services. The contract must be signed by authorized representatives of the hospice as well as the contracting party. The contract must include the following:

(A)

identification of the services to be provided;

(B)

a stipulation that services may be provided only with the express authorization of the hospice;

(C)

the manner in which the contracted services are coordinated, supervised, and evaluated by the hospice;

(D)

the delineation of the role(s) of the hospice and the contractor in the admission process, client and family health assessment, and the interdisciplinary team case conferences;

(E)

requirements for documentation that services are furnished in accordance with the agreement; and

(F)

the qualifications of the personnel providing the services.

(3)

The hospice must retain professional management responsibility for arranged services and ensure that they are furnished in a safe and effective manner by persons meeting the qualifications under this chapter, and in accordance with the client's plan of care and the other requirements of this subsection.

(4)

The hospice must retain responsibility for payment for services.

(5)

The hospice must ensure that inpatient care is furnished only in a licensed facility which meets the requirements of subsection (w) of this section, and the hospice's arrangement for inpatient care must be described in a contract and must meet the requirements of paragraph (2) of this subsection. The contract, at minimum, must meet the following requirements:

(A)

that the hospice furnishes to the inpatient provider a copy of the client's plan of care and specifies the inpatient services to be furnished;

(B)

that the inpatient provider has established policies consistent with those of the hospice and agrees to abide by the client care protocols established by the hospice for its clients;

(C)

that the medical record includes a record of all inpatient services and events, and that a copy of the discharge summary and, if requested, a copy of the medical record are provided to the hospice;

(D)

the party responsible for implementation of the provisions of the contract; and

(E)

that the hospice retains responsibility for appropriate hospice care training (to include palliative and end of life issues) of the personnel who provide the care under the agreement.

(g)

Prior to the start of care, the hospice physician or registered nurse must make an initial health assessment visit to determine the immediate care and support needs of the client.

(1)

The hospice physician or registered nurse must contact the client or client's representative other within 24 hours of receiving the physician's referral for hospice care to schedule an appointment for the initial health assessment.

(2)

The initial health assessment visit must be held within 48 hours after the hospice's receipt of the physician's referral for hospice care, unless ordered otherwise.

(3)

After the initial health assessment is completed, services approved by the physician may be rendered.

(h)

The hospice must perform and make available to each client admitted for hospice services a client-specific comprehensive health assessment that identifies the client's need for hospice care and the client's need for medical, nursing, social, emotional, and spiritual care which includes, but is not limited to, the palliation and management of the terminal illness and related conditions and support services for clients and their families.

(1)

The hospice must complete the comprehensive health assessment in a timely manner consistent with the client's immediate needs, but no later than seven calendar days after the start of hospice care.

(2)

The comprehensive health assessment must include:

(A)

input from the appropriate interdisciplinary team member(s) and an assessment of:

(i)

each client's physical condition, including functional ability and nutritional status;

(ii)

each client's pain and other symptoms and the management of discomfort and symptom relief;

(iii)

the client's and the client's family's social and emotional well-being;

(iv)

the client's spiritual orientation and needs;

(v)

the survivor risk factors to be considered in developing the bereavement care plan; and

(vi)

any other information necessary to develop an effective, interdisciplinary plan of care;

(B)

a review, repeated as necessary, of the client's medication list. The medication list must include all prescription and over-the-counter drugs to assure that all drugs are indicated and to identify any potential problems including, but not limited to:

(i)

ineffective drug therapy;

(ii)

significant side effects;

(iii)

significant drug interactions;

(iv)

significant drug or food interactions;

(v)

duplicate drug therapy; and

(vi)

noncompliance with drug therapy; and

(C)

a system of measures that captures significant outcomes that are essential to optimal hospice care, that are used in the care planning and coordination of services, and that are an essential part of the hospice's quality assessment and performance improvement program. The measures include, but are not limited to:

(i)

pain;

(ii)

nutritional status;

(iii)

continence;

(iv)

respiratory comfort;

(v)

infections;

(vi)

skin integrity;

(vii)

level of consciousness;

(viii)

anxiety;

(ix)

depression;

(x)

client emotional well being and satisfaction, including anxiety and depression;

(xi)

spiritual well being;

(xii)

social well being;

(xiii)

family knowledge and understanding; and

(xiv)

client and family satisfaction.

(3)

The comprehensive health assessment must be updated and revised:

(A)

as frequently as the condition of the client requires, as determined by:

(i)

changes in the client's physical, social, emotional or spiritual status;

(ii)

family environment; or

(iii)

suboptimal response to care, treatments or therapies; and

(B)

within 24 hours of the client's return home from an inpatient stay.

(i)

A written plan of care must be established and maintained for each client admitted to the hospice program, and the care provided to a client must be in accordance with the plan. The plan of care must specify the care and services necessary to meet the client-specific needs identified in the comprehensive health assessment described in subsection (h) of this section, include all client care orders, reflect planned interventions for problems identified, and ensure that care and services are appropriate to the severity level of each client's and the client's family's specific needs.

(1)

The plan must be established by the attending physician, the medical director or physician designee, and interdisciplinary team prior to providing care.

(2)

The plan must be reviewed and updated as necessary, at intervals specified in the plan, by the attending physician, the medical director or physician designee and interdisciplinary team. These reviews must be documented. An updated plan must include information from the client's comprehensive health assessment and information concerning the client's progress toward outcomes specified in the plan.

(3)

The plan must include:

(A)

a comprehensive health assessment of the client's needs and identification of the services including the management of pain and symptom relief. The plan must state in detail the scope and frequency of services needed to meet the client's and family's needs;

(B)

interventions to facilitate the management of pain and symptoms;

(C)

frequency and mix of services necessary to meet the client and family specific needs identified in the comprehensive health assessment;

(D)

measurable outcomes that the hospice anticipates will occur as a result of implementing and coordinating the plan of care;

(E)

drugs and treatments necessary to meet the needs of the patient as identified in the health assessment;

(F)

medical supplies and appliances necessary to meet the needs of the client identified in the health assessment; and

(G)

client and family understanding, agreement, and involvement with the plan as desired.

(j)

The interdisciplinary team may reassess the client for an appropriate level of care, as long as the reassessment does not reduce core services.

(k)

The hospice must inform the client of the availability of short term inpatient care for pain control, management, and respite purposes and the names of the facilities with which the agency has a contract agreement.

(l)

The hospice must document reasonable efforts to arrange for visits of clergy and other members of spiritual and religious organizations in the community to clients who request such visits and must advise all clients of this opportunity.

(m)

The hospice must ensure that substantially all the core services described in subsections (n)-(q) of this section are routinely provided directly by hospice employees. The hospice may use contracted staff if necessary to supplement its employees in order to meet the needs of clients during periods of peak client loads or under extraordinary circumstances. If contracting is used, the hospice must maintain professional, financial, and administrative responsibility for the services and assure that the qualifications of staff and services provided meet the requirements specified in subsections (n)-(q) of this section.

(n)

The hospice must provide nursing care and services by or under the supervision of a registered nurse.

(1)

Nursing services must be directed and staffed to assure that the nursing needs of the clients are met.

(2)

Client care responsibilities of nursing personnel must be specified.

(3)

Services must be provided in accordance with recognized standards of practice.

(o)

Medical social services must be provided by a social worker with a bachelor's degree in social work from an accredited college or university and must be under the direction of a physician.

(p)

In addition to palliation and management of terminal illness and related conditions, hospice physicians, including physician member(s) of the interdisciplinary team, must meet the general medical needs of the clients to the extent that these needs are not met by the attending physician. The hospice physician may meet these requirements either by directly providing the services or through coordination with the attending physician. If the attending physician is unavailable, the hospice physician is responsible for the care of the client.

(q)

Counseling services must be available to both the client and the family. Counseling includes dietary, spiritual, and any other counseling services for the client and family provided while the client is enrolled in the hospice program as well as bereavement counseling provided after the client's death.

(1)

Bereavement counseling service must be available to the family.

(A)

There must be an organized program for the provision of bereavement services under the supervision of the interdisciplinary team, a social worker, a mental health professional, a counselor, or other person with documented evidence of training and experience in dealing with bereavement and structured training in bereavement counseling. Persons providing bereavement counseling must have documented evidence of training in personnel folders.

(B)

The plan of care for these services must reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery. Services must be provided up to one year following the death of the client.

(2)

Dietary counseling must be planned by a registered or licensed dietitian, a person who is eligible for registration by the American Dietetic Association, or an individual who has documented equivalency in education or training. Dietary counseling must meet specific client needs as described in the client's plan of care. Although a dietitian need not be a full-time employee, there must be a record of this individual's credentials on file in the hospice. Dietary counseling must be supervised by a registered or licensed dietitian or a registered nurse.

(3)

Spiritual counseling must include notice to clients as to the availability of clergy as required under subsection (l) of this section. Spiritual counseling may be conducted by clergy or other members of a spiritual and religious organization of the client's choice.

(4)

Counseling may be provided by other members of the interdisciplinary team as well as by other professionals qualified by license or education to perform the type of counseling provided as determined by the hospice. Counseling, other than bereavement, dietary, or spiritual must be provided by persons qualified by license or education to perform the type of counseling to be provided in accordance with the client's plan of care. The counseling requirements do not preclude other members of the interdisciplinary team or other professionals from serving in the capacity of counselor. Nonprofessional volunteers may be used for listening and social interaction with clients.

(r)

The hospice must ensure that the services described in subsections (s)-(v) of this section are provided directly by hospice employees or under arrangements made by the hospice as specified in subsection (f) of this section. The hospice must maintain a system of communication and integration of services, whether provided directly or under arrangement, that ensures the identification of client needs and the ongoing liaison of all disciplines providing care.

(s)

Physical therapy services, occupational therapy services, and speech-language pathology services must be available, and when provided, must be offered in a manner consistent with accepted standards of practice.

(t)

Home health aide and homemaker services must be available and adequate in frequency to meet the needs of the clients. A home health aide must meet the training and competency evaluation requirements or the competency evaluation requirements as specified in §97.701(d)-(f) of this title (relating to Home Health Aides).

(1)

A registered nurse must visit the residence site no less frequently than every two weeks when aide services are being provided, and the visit must include an assessment of the aide services. The aide need not be present at each supervisory visit.

(2)

Written instructions for client care must be prepared by a registered nurse.

(u)

Medical supplies and appliances, including medications, must be provided as needed for the palliation and management of the terminal illness and related conditions.

(1)

All medications must be administered in accordance with accepted standards of practice.

(2)

The hospice must have and enforce a policy for the disposal of controlled medications maintained in the client's residence when those medications are no longer needed by the client.

(3)

Medications must be administered only by the following individuals:

(A)

a licensed nurse or physician;

(B)

a permitted home health medication aide;

(C)

the client if his or her attending physician has approved; or

(D)

another individual acting in accordance with applicable federal and state laws, or as specified in the rules adopted by the Board of Nurse Examiners at 22 TAC Chapter 218 (Delegation of Selected Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel).

(4)

The persons who are authorized to administer medications must be specified in the client's plan of care.

(v)

Inpatient care must be available for pain control, symptom management, or respite purposes.

(1)

Inpatient care must be provided by a licensed freestanding hospice or a hospital or nursing facility that meets the requirements specified in subsection (w)(1) and (5) of this section.

(2)

A hospice must develop, implement, maintain and evaluate an ongoing, comprehensive integrated self assessment of the quality and appropriateness of care provided, including inpatient care, home care, and care provided under arrangement. The findings must be documented and used by the hospice to correct identified problems and to revise hospice policies if necessary. Corrective action must be taken and tracked to ensure that improvements are sustained over time.

(A)

The hospice's quality assessment and performance improvement program must include, but not be limited to, the use of objective measures to demonstrate improved performance with regard to:

(i)

the system of measures that the hospice uses to determine if individual and aggregate outcomes are achieved compared to a previous time period;

(ii)

current clinical practice guidelines and professional practice standards applicable to hospice care;

(iii)

utilization data, as appropriate. This includes data, such as numbers of staff, types of visits, and inpatient care; and

(iv)

effectiveness and safety of services. This includes services such as parenteral therapy or infusion controlling devices, if provided; competency of clinical staff; promptness of service delivery; and appropriateness of responses to client and family problems.

(B)

The hospice must set priorities for performance improvement, considering prevalence and severity of identified problems and giving priority to improvement activities that affect clinical outcomes. The hospice must immediately correct identified problems that directly or potentially threaten the care and safety of clients.

(w)

A freestanding hospice that provides inpatient care directly must comply with the following standards in addition to the standards in subsections (a)-(v) of this section.

(1)

A freestanding hospice that provides inpatient care directly must have on-site 24-hour nursing service provided by registered nurses and licensed vocational nurses.

(A)

The facility must provide 24-hour nursing services which are sufficient to meet total nursing needs and which are in accordance with the client's plan of care. Each client must receive treatments, medications, and diet as prescribed, and must be kept comfortable, clean, well-groomed, and protected from accident, injury, and infection.

(B)

Each shift must include a registered nurse who provides and supervises direct client care.

(2)

The hospice must have a written plan, periodically rehearsed with staff, with procedures to be followed in the event of an internal or external disaster and for the care of casualties (clients and personnel) arising from such disasters.

(3)

The hospice must meet all federal, state, and local laws, regulations, and codes pertaining to health and safety, such as provisions regulating the following:

(A)

construction, maintenance, and equipment for the hospice;

(B)

sanitation;

(C)

communicable and reportable diseases; and

(D)

post-mortem procedures.

(4)

Except as provided in this subsection, the hospice must meet National Fire Protection Association 101, Code for Safety to Life from Fire in Buildings and Structures, 1994 Edition (NFPA 101), Chapter 12 (concerning new health care occupancies) and Chapter 13 (concerning existing health care occupancies), published by the National Fire Protection Association (NFPA). All documents published by the NFPA as referenced in this subsection may be obtained by writing the National Fire Protection Association, Post Office Box 9101, Batterymarch Park, Quincy, Massachusetts 02169, or calling 1-800-344-3555.

(A)

The Texas Department of Human Services (DHS) recognizes the Health Care Financing Administration (HCFA) waiver of specific provisions of the NFPA 101 required by this paragraph for a certified hospice for as long as HCFA honors the waiver, if the waiver would not adversely affect the health and safety of the clients and rigid application of specific provisions of the NFPA 101 would result in unreasonable hardship for the hospice. DHS may waive specific provisions of the NFPA 101 for a licensed hospice, if the waiver would not adversely affect the health and safety of the clients; and rigid application of specific provisions of the NFPA 101 would result in unreasonable hardship for the hospice.

(B)

Any existing facility of two or more stories that is not of fire-resistive construction and is participating on the basis of a waiver of construction type or height, may not house blind, nonambulatory, or physically disabled clients above the street-level floor unless the facility is one of the following construction types (as defined in the NFPA 101)

(i)

Type II (1,1,1)-protected noncombustible;

(ii)

fully-sprinklered Type II (0,0,0)-noncombustible;

(iii)

fully-sprinklered Type III (2,1,1)-protected ordinary;

(iv)

fully-sprinklered Type V (1,1,1)-protected wood frame; or

(v)

achieves a passing score on the Fire Safety Evaluation System (FSES) for Health Care Occupancies, National Fire Codes, Volume 10, NFPA 101A, Guide on Alternative Approaches to Life Safety, Chapter 3, 1995 Edition published by the NFPA.

(5)

The hospice must be designed and equipped for the comfort and privacy of each client and family member. The hospice must provide:

(A)

physical space for private client and family visiting;

(B)

accommodations for family members to remain with the client throughout the night;

(C)

accommodations for family privacy after a client's death;

(D)

decor that is homelike in design and function; and

(E)

accommodations where clients are permitted to receive visitors at any hour, including small children.

(6)

Client rooms must be designed and equipped for adequate nursing care and the comfort and privacy of clients. Each client's room must:

(A)

be equipped with or conveniently located near toilet and bathing facilities;

(B)

be at or above grade level;

(C)

contain a suitable bed for each client and other appropriate furniture;

(D)

have closet space that provides security and privacy for clothing and personal belongings;

(E)

contain no more than four beds;

(F)

measure at least 100 square feet for a single room or 80 square feet for each client for a multiclient room; and

(G)

be equipped with a device for calling the staff member on duty.

(7)

For an existing building, DHS recognizes the HCFA waiver for the space and occupancy requirements of paragraph (6)(E) and (F) of this subsection for a certified hospice for as long as HCFA honors the waiver, if DHS finds that the requirements would result in unreasonable hardship on the hospice if strictly enforced, and the waiver serves the particular needs of the clients and does not adversely affect their health and safety. For an existing building, DHS may waive the space and occupancy requirements of paragraph (6)(E) and (F) of this subsection for a licensed hospice for as long as it is considered appropriate, if it finds that the requirements would result in unreasonable hardship on the hospice if strictly enforced and the waiver serves the particular needs of the clients and does not adversely affect their health and safety.

(8)

The hospice must provide bathroom facilities. The bathroom facilities must include the following:

(A)

an adequate supply of hot water at all times for client use; and

(B)

plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by clients.

(9)

The hospice must have available at all times a quantity of linen essential for the proper care and comfort of clients. Linens must be handled, stored, processed, and transported in such a manner as to prevent the spread of infection.

(10)

The hospice must make provisions for isolating clients with infectious diseases.

(11)

The hospice must provide and supervise meal service and menu planning. The hospice must:

(A)

serve at least three meals or their equivalent each day at regular times, with not more than 14 hours between a substantial evening meal and breakfast;

(B)

procure, store, prepare, distribute, and serve all food under sanitary conditions;

(C)

have a staff member trained or experienced in food management or nutrition if the staff member responsible for dietary services is not a dietitian.

(i)

The person must:

(I)

be a graduate of a dietetic technician or dietetic assistant training program, correspondence or classroom, approved by the American Dietetic Association; or

(II)

be a graduate of a state-approved course that provided 90 or more hours of classroom instruction in food service supervision and must have experience as a supervisor in a health care institution with consultation from a dietitian; or

(III)

have training and experience in food service supervision and management in a military service equivalent in content to the program in this paragraph.

(ii)

The staff member is responsible for:

(I)

planning menus that meet the nutritional needs of each client. The menus must follow the orders of the client's physician and, to the extent medically possible, follow the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences (Recommended Dietary Allowances, 10th ed., 1989, available from the Printing and Publications Office, National Academy of Sciences, Washington, D.C. 20418). The menus must be approved by a licensed dietitian. The hospice must use written guidelines for substitutions that are approved by the licensed dietitian; and

(II)

supervising the meal preparation and meal service that is conducted to ensure that the menu plan is followed; and

(D)

have the menus for those clients who require medically prescribed special diets. The menus must be planned by a dietitian who monitors the preparation and serving of meals to ensure that the client accepts the special diet.

(12)

The hospice must provide appropriate methods and procedures for dispensing and administering medications. Whether medications are obtained from community or institutional pharmacists or stocked by the facility, the facility must be responsible for medications for its clients, insofar as they are covered under the program, and for ensuring that pharmaceutical services are provided in accordance with accepted professional principles and appropriate federal and state laws.

(A)

The hospice must employ a licensed pharmacist or have a formal agreement with a licensed pharmacist to advise the hospice on ordering, storage, administration, disposal, and recordkeeping of medications.

(B)

A physician must order all medications for the client.

(C)

If the medication order is verbal, the physician must give it only to a licensed nurse, pharmacist, or another physician.

(D)

If the medication order is verbal, the individual receiving the order must record and sign it immediately and have the prescribing physician sign it in a manner consistent with good medical practice.

(E)

Medications must be administered only by one of the following individuals:

(i)

a licensed nurse or physician;

(ii)

a permitted home health medication aide or an employee as specified in the rules adopted by the Board of Nurse Examiners at 22 TAC Chapter 218 (Delegation of Selected Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel); or

(iii)

the client if his or her attending physician has approved.

(F)

The pharmaceutical service must have procedures for control and accountability of all medications throughout the facility. Medications must be dispensed in compliance with federal and state laws. Records of receipt and disposition of all controlled medications must be maintained in sufficient detail to enable an accurate reconciliation. The pharmacist must determine that medication records are in order and that an account of all controlled medications is maintained and reconciled.

(G)

The labeling of medications must be based on currently accepted professional principles, and must include the appropriate accessory and cautionary instructions, as well as the expiration date when applicable.

(H)

In accordance with state and federal laws, all medications must be stored in locked compartments under proper temperature controls and only authorized personnel must have access to the keys. Separately locked compartments must be provided for storage of controlled medications listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, 21 United States Code, §801 et seq and other medications that are subject to abuse, except under single-unit package medication distribution systems in which the quantity stored is minimal and a missing dose is readily detected. An emergency medication kit must be kept readily available.

(I)

Controlled medications no longer needed by the client must be disposed of in compliance with state requirements. The pharmacist and registered nurse must dispose of medications and prepare a record of the disposal.

§97.404.Standards Specific to Agencies Licensed to Provide Personal Assistance Services.

(a)

In addition to meeting the standards in Subchapter C of this chapter (relating to Minimum Standards for All Home and Community Support Services Agencies), an agency holding a license with the category of personal assistance services must meet the standards of this section.

(b)

Personal assistance services as defined in §97.2 of this title (relating to Definitions) may be performed by an unlicensed person who is at least 18 years of age and has demonstrated competency, when competency cannot be determined through education and experience, to perform the tasks assigned by the supervisor. An unlicensed person who is under 18 years of age, is a high school graduate or is enrolled in a vocational educational program, and has demonstrated competency to perform the tasks assigned by the supervisor, may perform personal assistance services.

(c)

The following tasks may be performed under a personal assistance services category:

(1)

personal care including feeding, preparing meals, transferring, toileting, ambulation and exercise, grooming, bathing, dressing, routine care of hair and skin, and assistance with medications that are normally self administered;

(2)

health-related tasks that may be delegated by a registered nurse (RN) in accordance with the agency's written policy adopted, implemented and enforced to ensure compliance with the rules of the Board of Nurse Examiners for the State of Texas adopted at 22 TAC §§218.1-218.11 (Delegation of Selected Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel) except for nursing tasks that may not be delegated and nursing tasks that may not be routinely delegated;

(3)

health-related tasks that are not the practice of professional nursing under the memorandum of understanding between the Texas Department of Human Services (DHS) and the Board of Nurse Examiners; and

(4)

health-related tasks that are delegated by a physician under the Occupations Code, Chapter 157.

(d)

The agency must ensure that when developing its operational policies, that the policies are considerate of principles of individual and family choice and control, functional need, and accessible and flexible services.

(e)

In addition to the client record requirements in §97.301(a)(9) of this title (relating to Client Records), the client file must include the following:

(1)

documentation of determination of services based on an on-site visit by the supervisor where services will be primarily delivered and records of supervisory visits, if applicable;

(2)

individualized service plan developed, agreed upon, and signed by the client or family and the agency. The individualized service plan must include, but not be limited to the following:

(A)

types of services, supplies, and equipment to be provided;

(B)

locations of services;

(C)

frequency and duration of services;

(D)

planned date of service initiation;

(E)

charges for services rendered if the charges will be paid in full or in part by the client or significant other(s), or on request; and

(F)

plan of supervision;

(3)

documentation that the services have been provided according to the individualized service plan;

(f)

In addition to the written policies required by §97.245 of this title (relating to Staffing Policies) the agency must adopt and enforce a written policy addressing the supervision of personnel with input from the client or family on the frequency of supervision.

(1)

Supervision of personnel must be in accordance with the agency's policies and applicable state laws and rules, including 22 TAC, §§218.1-218.11, concerning the delegation of selected nursing tasks by registered professional nurses to unlicensed personnel adopted by the Board of Nurse Examiners.

(2)

A supervisor must be a licensed nurse or have completed two years of full-time study at an accredited college or university. An individual with a high school diploma or general equivalence diploma (GED) may substitute one year of full-time employment in a supervisory capacity in a health care facility, agency, or community-based agency for each required year of college.

(3)

The client in a client managed attendant care program funded by DHS or Texas Rehabilitation Commission is not required to meet the standard in paragraph (2) of this subsection.

(g)

Tube feedings and medication administration through a permanently placed gastrostomy tube (g-tube) in accordance with subsection (c)(3) of this section may be performed by an unlicensed person only after successful completion of the training and competency program and procedures described in paragraphs (1)-(5) of this subsection.

(1)

The training and competency program for the performance of g-tube feedings by an unlicensed person must be taught by an RN, physician, physician assistant (PA), or qualified trainer. A qualified trainer must:

(A)

have successfully completed the training and competency program described in paragraphs (2) and (3) of this subsection taught by an RN, physician, or PA;

(B)

have demonstrated upon return demonstration to an RN, physician or PA the performance of the task and the ability to teach the task; and

(C)

have been deemed competent by an RN, physician, or PA to train unlicensed personnel in these procedures. Documentation of competency to perform, train and teach must be maintained in the employee's or contractor's file. Competency must be evaluated and documented by an RN, physician or PA annually.

(2)

The minimum training program must include:

(A)

a description of the g-tube placement, including its purpose;

(B)

infection control procedures and universal precautions to be utilized when performing g-tube feedings or medication administration through a g-tube;

(C)

a description of conditions which must be reported to the client or the primary care giver, or in the absence of the primary care giver, to the agency administrator, supervisor, or the client's physician. The description of conditions must include a plan to be effected if the g-tube comes out or is not positioned correctly to ensure medical attention is provided within one hour;

(D)

review of a written procedure for g-tube feeding or medication administration through a g-tube. The written procedure must be equivalent to current acceptable nursing standards of practice, including addressing the crushing of medications;

(E)

conditions under which g-tube feeding or medication administration must not be performed; and

(F)

demonstration of a g-tube feeding and medication administration to a client. If the trainee will become a qualified trainer, the demonstration must be done by the RN, PA, or physician. If the trainee will not become a qualified trainer, the demonstration may be done by an RN, PA, physician, or qualified trainer.

(3)

The minimum competency evaluation must be documented and maintained in the employee's file and must include:

(A)

a score of 100% on a written multiple choice test that consists of situational questions to include the criteria in paragraph (2)(A)-(E) of this subsection and evaluate the trainee's judgment and understanding of the essential skills, risks, and possible complications of a g-tube feeding or medication administration through a g-tube;

(B)

a skills checklist demonstrating that the trainee has successfully completed the necessary skills for a g-tube feeding and medication administration via g-tube, and if the trainee will become a qualified trainer, the skills checklist must also demonstrate the ability to teach another person to perform the task. The skills checklist must be completed by an RN, physician, or PA if the trainee will become a qualified trainer. The skills checklist for a trainee who will not become a qualified trainer may be completed by an RN, physician, PA, or qualified trainer; and

(C)

documentation of an accurate demonstration of the g-tube feeding and medication administration performed by the trainee as required by paragraph (2)(F) of this subsection. If the trainee will become a qualified trainer, documentation of competency to teach this task must be maintained in the file of the qualified trainer. The person responsible for the training of the trainee must document the successful demonstration of the g-tube feeding and medication administration via g-tube by the trainee and the trainee's competency to perform this task in the trainee's file.

(4)

The client or primary care giver must provide information on the client's g-tube feeding or medication administration to the agency supervisor. If the client is not capable of directing his or her own care, the client's primary care giver must be present to instruct and orient the supervisor regarding the client's g-tube feeding and medication regime. A copy of the current regime including unique conditions specific to the client must be placed in the client's file by the agency supervisor and provided to the respite care giver. The respite care giver must be oriented by the client, the client's primary care giver, or the agency supervisor. The supervisor of the delivery of these services must have successfully completed a training and competency program outlined in paragraphs (2) and (3) of this subsection or be a qualified trainer.

(5)

Legend medications that are to be administered must be in a legally labeled container from a pharmacy that contains the name of the client. Instructions for dosages according to weight or age for over the counter drugs commonly given the client must be furnished by the primary care giver to the respite care giver performing the tube feeding or medication administration.

§97.405.Standards Specific to Agencies Licensed to Provide Home Dialysis Services.

(a)

License designation. An agency may not provide peritoneal dialysis or hemodialysis services in a client's residence, independent living environment, or other appropriate location unless the agency holds a license to provide licensed home health or licensed and certified home health services and designated to provide home dialysis services. In order to receive a home dialysis designation, the agency must meet the licensing standards specified in this section and the standards for home health services in accordance with Subchapter C of this title (relating to Minimum Standards for All Home and Community Support Services Agencies) and §97.401 of this title (relating to Standards Specific to Licensed Home Health Services) except for §97.401(b)(2)(A) and (B) of this title (relating to Minimum Standards for All Home and Community Support Services Agencies). If there is a conflict between the standards specified in this section and those specified in Subchapter C of this title (relating to Minimum Standards for All Home and Community Support Services Agencies) §97.401 of this title (relating to Standards Specific to Licensed Home Health Services), the standards specified in this section will apply to the home dialysis services.

(b)

Governing body. An agency must have a governing body. The governing body must appoint a medical director and the physicians who are on the agency's medical staff. The governing body must annually approve the medical staff policies and procedures. The governing body on a biannual basis must review and consider for approval continuing privileges of the agency's medical staff. The minutes from the governing body of the agency must be on file in the agency office.

(c)

Qualifications and responsibilities of the medical director.

(1)

Qualifications. The medical director must be a physician licensed in the State of Texas who:

(A)

is eligible for certification or is certified in nephrology or pediatric nephrology by a professional board; or

(B)

during the five-year period prior to September 1, 1996, served at least 12 months as director of a dialysis facility or program.

(2)

Responsibilities. The medical director must be responsible for:

(A)

participating in the selection of a suitable treatment modality for all clients;

(B)

assuring adequate training of nurses in dialysis techniques;

(C)

assuring adequate monitoring of the client and the dialysis process; and

(D)

assuring the development and availability of a client care policy and procedures manual and its implementation.

(d)

Personnel files. An agency must have individual personnel files on all physicians, including the medical director. The file must include the following:

(1)

a curriculum vitae which documents undergraduate, medical school, and all pertinent post graduate training; and

(2)

evidence of current licensure, and evidence of current United States Drug Enforcement Administration certification, Texas Department of Public Safety registration, and the board eligibility or certification, or the experience or training described in subsection (c) (1) of this section.

(e)

Provision of services. An agency which provides home staff- assisted dialysis must, at a minimum, provide nursing services, nutritional counseling, and medical social service. These services must be provided as necessary and appropriate at the client's home, by phone, or by a client's visit to a licensed ESRD facility in accordance with this subsection. The use of dialysis technicians in home dialysis is prohibited.

(1)

Nursing services.

(A)

A registered nurse (RN), licensed by the State of Texas, who has at least 18 months experience in hemodialysis obtained within the last 24 months and has successfully completed the orientation and skills education described in subsection (f) of this section, must be available whenever dialysis treatments are in progress in a client's home. The agency administrator must designate a qualified alternate to this registered nurse.

(B)

Dialysis services must be supervised by an RN who meets the qualifications for a supervising nurse as set out in §97.244(b)(3) of this title (relating to Staffing Qualifications).

(C)

Dialysis services must be provided by a qualified licensed nurse who:

(i)

is licensed as a registered or licensed vocational nurse by the State of Texas;

(ii)

has at least 18 months experience in hemodialysis obtained within the last 24 months; and

(iii)

has successfully completed the orientation and skills education described in subsection (f) of this section.

(2)

Nutritional counseling. A dietitian who meets the qualifications of this paragraph must be employed by or under contract with the agency to provide services. A qualified dietitian must meet the definition of dietitian in §97.2 of this title (relating to Definitions) and have at least one year of experience in clinical nutrition after obtaining eligibility for registration by the American Dietetic Association, Commission on Dietetic Registration.

(3)

Medical social services. A social worker who meets the qualifications established in this paragraph must be employed by or be under contract with the agency to provide services. A qualified social worker is a person who:

(A)

is currently licensed under the laws of the State of Texas as a social worker and has a master's degree in social work from a graduate school of social work accredited by the Council on Social Work Education; or

(B)

has served for at least two years as a social worker, one year of which was in a dialysis facility or program prior to September 1, 1976, and has established a consultative relationship with a licensed master social worker.

(f)

Orientation, skills education, and evaluation.

(1)

All personnel providing dialysis in the home must receive orientation and skills education and demonstrate knowledge of the following:

(A)

anatomy and physiology of the normal kidney;

(B)

fluid, electrolyte, and acid-base balance;

(C)

pathophysiology of renal disease;

(D)

acceptable laboratory values for the client with renal disease;

(E)

theoretical aspects of dialysis;

(F)

vascular access and maintenance of blood flow;

(G)

technical aspects of dialysis;

(H)

peritoneal dialysis catheter, testing for peritoneal membrane equilibration, and peritoneal dialysis adequacy clearance, if applicable;

(I)

the monitoring of clients during treatment, beginning with treatment initiation through termination;

(J)

the recognition of dialysis complications, emergency conditions, and institution of the appropriate corrective action. This includes training agency personnel in emergency procedures and how to use emergency equipment;

(K)

psychological, social, financial, and physical complications of chronic dialysis;

(L)

care of the client with chronic renal failure;

(M)

dietary modifications and medications for the uremic client;

(N)

alternative forms of treatment for ESRD;

(O)

the role of renal health team members (physician, nurse, social worker, and dietitian);

(P)

performance of laboratory tests (hematocrit and blood glucose);

(Q)

the theory of blood products and blood administration; and

(R)

water treatment to include:

(i)

standards for treatment of water used for dialysis as described in §3.2.1 (Hemodialysis Systems) and §3.2.2 (Maximum Level of Chemical Contaminants) of the American National Standard, Hemodialysis Systems, March 1992 Edition, published by the Association for the Advancement of Medical Instrumentation (AAMI), 3330 Washington Boulevard, Suite 500, Arlington, Virginia 22201. Copies of the standards are indexed and filed in the Texas Department of Human Services, 701 W. 51st Street, Austin, Texas 78751, and are available for public inspection during regular working hours;

(ii)

systems and devices;

(iii)

monitoring; and

(iv)

risks to clients of unsafe water.

(2)

The requirements for the orientation and skills education period for licensed nurses are as follows.

(A)

The agency must develop an 80-hour written orientation program which includes classroom theory and direct observation of the licensed nurse performing procedures on a client in the home.

(i)

The orientation program must be provided by a registered nurse qualified under subsection (e)(1) of this section to supervise the provision of dialysis services by a licensed nurse.

(ii)

The licensed nurse must pass a written skills examination or competency evaluation at the conclusion of the orientation program and prior to the time the licensed nurse delivers independent client care.

(B)

The licensed nurse must complete the required classroom component as described in paragraph (1)(A)-(E), (K)-(O), (Q) and (R) of this subsection and satisfactorily demonstrate the skills described in paragraph (1)(F)-(J) and (P) of this subsection. The orientation program may be waived by successful completion of the written examination as described in subparagraph (A)(ii) of this paragraph.

(C)

The supervising nurse or qualified designee must complete an orientation competency skills checklist for each licensed nurse to reflect the progression of learned skills, as described in subsection (f) (1) of this section.

(D)

Prior to the delivery of independent client care, the supervising nurse or qualified designee must directly supervise the licensed nurse for a minimum of three dialysis treatments and ensure satisfactory performance. Dependent upon the trainee's experience and accomplishments on the skills checklist, additional supervised dialysis treatments may be required.

(E)

Continuing education for employees must be provided quarterly.

(F)

Performance evaluations must be done annually.

(G)

The supervising nurse or qualified designee must provide direct supervision to the licensed nurse providing dialysis services monthly or more often if necessary. Direct supervision means that the supervising nurse is on the premises but not necessarily immediately present where dialysis services are being provided.

(g)

Hospital transfer procedure. An agency must establish an effective procedure for the immediate transfer to a local Medicare-certified hospital for clients requiring emergency medical care. The agency must have a written transfer agreement with such a hospital, or all physician members of the agency's medical staff must have admitting privileges at such a hospital.

(h)

Backup dialysis services. An agency which supplies home staff- assisted dialysis must have an agreement with a licensed end stage renal disease (ESRD) facility to provide backup outpatient dialysis services.

(i)

Coordination of medical and other information. An agency must provide for the exchange of medical and other information necessary or useful in the care and treatment of clients transferred between treating facilities. This provision must also include the transfer of the client care plan, hepatitis B status, and long term program.

(j)

Transplant recipient registry program. An agency must ensure that the names of clients awaiting cadaveric donor transplantation are entered in a recipient registry program.

(k)

Testing for hepatitis B. An agency must conduct routine testing of home dialysis clients and agency employees to ensure detection of hepatitis B in employees and clients.

(1)

An agency must offer hepatitis B vaccination to previously unvaccinated, susceptible new staff members in accordance with 29 Code of Federal Regulations, §1910.1030(f)(1)-(2) (Bloodborne Pathogens).

(A)

Staff vaccination records must be maintained in each staff member's personnel file.

(B)

New staff members providing home dialysis care must be screened for hepatitis B surface antigen (Hbsag) and the results reviewed prior to the staff providing client care, unless the new staff member provides the agency documentation of positive serologic response to hepatitis B vaccine.

(C)

An agency must establish, implement, and enforce a policy for repeated serologic screening of staff. The repeated serologic screening must be based on each staff member's HbsAg/antibody to HbsAg (anti-Hbs), and must be congruent with Appendices i and ii of the National Surveillance of Dialysis Associated Disease in the United States, 1993, published by the United States Department of Health and Human Services (USDHHS). This document may be obtained by writing the Home and Community Support Services Program, Texas Department of Human Services, 701 W. 51st Street, Austin, Texas 78751 or calling 438-3011 or writing the United States Department of Health and Human Services at the Public Health Service, Centers for Disease Control and Prevention, National Center for Infectious Diseases, Hospital Infection Program, Mail Stop C01, Atlanta, Georgia 30333, or calling 404-639-2318.

(2)

With the advice and consent of a client's nephrologist or attending physician, an agency must make the hepatitis B vaccine available to a client who is susceptible to hepatitis B, provided that the client has coverage or is willing to pay for vaccination.

(A)

An agency must make available to clients literature describing the risks and benefits of the hepatitis B vaccination.

(B)

Candidates for home dialysis must be screened for HbsAg within one month before or at the time of admission to the agency.

(C)

Repeated serologic screening must be based on the antigen or antibody status of the client.

(D)

Monthly screening for HbsAg is required for clients whose previous test results are negative for HbsAg.

(E)

Screening of HbsAg-positive or anti-HbsAg-positive clients may be performed on a less frequent basis, provided that the agency's policy on this subject remains congruent with Appendices i and ii of the National Surveillance of Dialysis Associated Diseases in the United States, 1993, published by the USDHHS.

(l)

CPR certification. All direct client care employees must have current CPR certification.

(m)

Initial admission assessment. Assessment of the client's residence must be made to ensure a safe physical environment for the performance of dialysis. The initial admission assessment must be performed by a qualified registered nurse who meets the qualifications under subsection (e)(1)(A) of this section.

(n)

Client long-term program. The agency must develop a long-term program for each client admitted to home dialysis. Criteria must be defined in writing and must provide guidance to the agency in the selection of clients suitable for home staff-assisted dialysis and in noting changes in a client's condition which would require discharge from the program.

(o)

Client history and physical. The agency must ensure that the history and physical is conducted upon the client's admission or no more than six months prior to the date of admission, then annually after the date of admission.

(p)

Physician orders. If home staff-assisted dialysis is selected, the physician must prepare orders outlining specifics of prescribed treatment.

(1)

If these physician's orders are received verbally, they must be confirmed in writing within a reasonable time frame. An agency must adopt and enforce a policy on the time frame for the countersignature of a physician's verbal orders. Medical orders for home staff-assisted dialysis must be revised as necessary but reviewed and updated at least every six months.

(2)

The initial orders for home staff-assisted dialysis must be received prior to the first treatment and must cover all pertinent diagnoses, including mental status, prognosis, functional limitations, activities permitted, nutritional requirements, medications and treatments, and any safety measures to protect against injury. Orders for home staff-assisted dialysis must include frequency and length of treatment, target weight, type of dialyzer, dialysate, dialysate flow rate, heparin dosage, and blood flow rate, and must specify the level of preparation required for the care giver, such as a licensed vocational nurse or registered nurse.

(q)

Client care plan. The client care plan must be developed after consultation with the client and the client's family by the interdisciplinary team. The interdisciplinary team must include the physician, the registered nurse, the dietitian, and the qualified social worker responsible for planning the care delivered to the home staff-assisted dialysis patient.

(1)

The initial client care plan must be completed by the interdisciplinary team within ten calendar days after the first home dialysis treatment.

(2)

The client care plan must implement the medical orders and must include services to be rendered, such as the identification of problems, methods of intervention, and the assignment of health care personnel.

(3)

The client care plan must be in writing, be personalized for the individual, and reflect the ongoing medical, psychological, social, nutritional, and functional needs of the client, including treatment goals.

(4)

The client care plan must include written evidence of coordination with other service providers, such as dialysis facilities or transportation providers, as needed to assure the provision of safe care.

(5)

The client care plan must include written evidence of the client's or client's legal representative's input and participation, unless they refuse to participate. At a minimum, the client care plan must demonstrate that the content was shared with the client or the client's legal representative.

(6)

For non-stabilized clients, where there is a change in modality, unacceptable laboratory work, uncontrolled weight changes, infections, or a change in family status, the client care plan must be reviewed at least monthly by the interdisciplinary team. Evidence of the review of the client care plan with the client and the interdisciplinary team to evaluate the client's progress or lack of progress toward the goals of the care plan, and interventions taken when progress toward stabilization or the goals are not achieved, must be documented and included in the client record.

(7)

For a stable client, the client care plan must be reviewed and updated as indicated by any change in the client's medical, nutritional, or psychosocial condition or at least every six months. The long term program must be revised as needed and reviewed annually. Evidence of the review of the client care plan with the client and the interdisciplinary team to evaluate the client's progress or lack of progress toward the goals of the care plan, and interventions taken when the goals are not achieved, must be documented and included in the client record.

(r)

Medication administration. Medications must be administered only by licensed personnel.

(s)

Client records. In addition to the applicable information described in §97.301(a)(9) of this title (relating to Client Records), records of home staff assisted dialysis clients must include the following:

(1)

a medical history and physical;

(2)

clinical progress notes by the physician, qualified licensed nurse, qualified dietitian, and qualified social worker;

(3)

dialysis treatment records;

(4)

laboratory reports;

(5)

a client care plan;

(6)

a long-term program; and

(7)

documentation of supervisory visits.

(t)

Water treatment.

(1)

Water used for dialysis purposes must be analyzed for chemical contaminants every six months. Additional chemical analysis must be conducted if test results exceed the maximum levels of chemical contaminants listed in §3.2.2 (Maximum Level of Chemical Contaminants) of the American National Standards for Hemodialysis Systems, March 1992 Edition, published by the AAMI. Copies of the standards are indexed and filed in the Texas Department of Human Services, 701 W. 51st Street, Austin, Texas 78751, and are available for public inspection during regular working hours.

(2)

Water used for dialysis must be treated as necessary to maintain a continuous water supply that is biologically and chemically compatible with acceptable dialysis techniques.

(3)

Water used to prepare dialysate must meet the requirements set forth in §3.2.1 (Hemodialysis Systems) and §3.2.2 (Maximum Level of Chemical Contaminants), March 1992 Edition, published by the AAMI. Copies of the standards are indexed and filed in the Texas Department of Human Services, 701 W. 51st Street, Austin, Texas 78751, and are available for public inspection during regular working hours.

(4)

Records of test results and equipment maintenance must be maintained at the agency.

(u)

Equipment testing. An agency must adopt and enforce a policy to describe how the nurse will check the machine for conductivity, temperature, and Ph prior to treatment, and describe the equipment required for these tests. The equipment must be available for use prior to each treatment. This policy must reflect current standards.

(v)

Preventive maintenance for equipment. An agency must develop, and enforce a written preventive maintenance program to ensure client care related equipment receives electrical safety inspections, if appropriate, and maintenance at least annually or more frequently if recommended by the manufacturer. The preventive maintenance may be provided by agency or contract staff qualified by training or experience in the maintenance of dialysis equipment.

(1)

All equipment used by a client in home dialysis must be maintained free of defects which could be a potential hazard to clients, the client's family or agency personnel.

(A)

Agency staff must be able to identify malfunctioning equipment and report such equipment to the appropriate agency staff. Malfunctioning equipment must be immediately removed from use.

(B)

Written evidence of all preventive maintenance and equipment repairs must be maintained.

(C)

After repairs or alterations are made to any equipment, the equipment must be thoroughly tested for proper operation before returning to service.

(D)

An agency must comply with the federal Food, Drug, and Cosmetic Act, 21 United States Code (USC), §360i(b), concerning reporting when a medical device as defined in 21 USC, §321(h) has or may have caused or contributed to the injury or death of an agency client.

(2)

In the event that the water used for dialysis purposes or home dialysis equipment is found not to meet safe operating parameters, and corrections can not be effected to ensure safe care promptly, the client must be transferred to a licensed hospital (if inpatient care is required) or licensed ESRD facility until such time as the water or equipment is found to be operating within safe parameters.

(w)

Reuse or reprocessing of medical devices. Reuse or reprocessing of disposable medical devices, including but not limited to, dialyzers, end-caps, and blood lines must be in accordance with this subsection.

(1)

An agency's reuse practice must comply with the American National Standard, Reuse of Hemodialyzers, 1993 Edition, published by the AAMI. A facility must adopt and enforce a policy for dialyzer reuse criteria (including any agency-set number of reuses allowed) which is included in client education materials.

(2)

A transducer protector must be replaced when wetted during a dialysis treatment and must be used for one treatment only.

(3)

Arterial lines may be reused only when the arterial lines are labeled to allow for reuse by the manufacturer and the manufacturer-established protocols for the specific line have been approved by the United States Food and Drug Administration.

(4)

An agency must consider and address the health and safety of clients sensitive to disinfectant solution residuals.

(5)

An agency must provide each client and the client's family or legal representative with information regarding the reuse practices of the agency, the opportunity to tour the reuse facility used by the agency, and the opportunity to have questions answered.

(6)

An agency practicing reuse of dialyzers must:

(A)

ensure that dialyzers are reprocessed via automated reprocessing equipment in a licensed ESRD facility or a centralized reprocessing facility;

(B)

maintain responsibility and accountability for the entire reuse process;

(C)

adopt and enforce policies to ensure that the transfer and transport of used and reprocessed dialyzers to and from the client's home does not increase contamination of the dialyzers, staff, or the environment; and

(D)

ensure that DHS staff has access to the reprocessing facility as part of an agency inspection.

(x)

Laboratory services. Provision of laboratory services must be as follows.

(1)

All laboratory services ordered for the client by a physician must be performed by a laboratory which meets the Clinical Laboratory Improvement Amendments of 1988, 42 United States Code, §263a, Certification of Laboratories (CLIA 1988) and in accordance with a written arrangement or agreement with the agency. CLIA 1988 applies to all agencies with laboratories that examine human specimens for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings.

(2)

Copies of all laboratory reports must be maintained in the client's medical record.

(3)

Hematocrit and blood glucose tests may be performed at the client's home in accordance with §97.284 of this title (relating to Laboratory Services). Results of these tests must be recorded in the client's medical record and signed by the qualified licensed nurse providing the treatment. Maintenance, calibration, and quality control studies must be performed according to the equipment manufacturer's suggestions, and the results must be maintained at the agency.

(4)

Blood and blood products must only be administered to dialysis clients in their homes by a licensed nurse or physician.

(y)

Home dialysis supplies. Supplies for home dialysis must meet the following requirements.

(1)

All drugs, biologicals, and legend medical devices must be obtained for each client pursuant to a physician's prescription in accordance with applicable rules of the Texas Board of Pharmacy.

(2)

In conjunction with the client's attending physician, the agency must ensure that there are sufficient supplies maintained in the client's home to perform the scheduled dialysis treatments and to provide a reasonable number of backup items for replacements, if needed, due to breakage, contamination, or defective products. All dialysis supplies, including medications, must be delivered directly to the client's home by a vendor of such products. However, agency personnel may transport prescription items from a vendor's place of business to the client's home for the client's convenience, so long as the item is properly labeled with the client's name and direction for use. Agency personnel may transport medical devices for reuse.

(z)

Emergency procedures. The agency must adopt and enforce policies and procedures for emergencies addressing fire, natural disaster, and medical emergencies.

(1)

Procedures must be individualized for each client to include the appropriate evacuation from the home and emergency telephone numbers. Emergency telephone numbers must be posted at each client's home and must include 911 if available, the number of the physician, the ambulance, the qualified registered nurse on call for home dialysis, and any other phone number deemed as an emergency number.

(2)

The agency must ensure that the client and the client's family know the agency's procedures for emergencies.

(3)

The agency must ensure that the client and the client's family know the procedure for disconnecting the dialysis equipment.

(4)

The agency must ensure that the client and the client's family know emergency call procedures.

(5)

A working telephone must be available during the dialysis procedure.

(6)

Depending on the kinds of medications administered, an agency must have available emergency drugs as specified by the medical director.

(7)

In the event of a medical emergency requiring transport to a hospital for care, the agency must assure the following:

(A)

the receiving hospital is given advance notice of the client's arrival;

(B)

the receiving hospital is given a description of the client's health status; and

(C)

the selection of personnel, vehicle, and equipment are appropriate to effect a safe transfer.

§97.406.Standards for Agencies Providing Psychoactive Services.

An agency that provides skilled nursing psychoactive treatments must comply with the requirements of this section.

(1)

An agency must adopt and enforce a written policy relating to the provision of psychoactive treatments consistent with this section.

(2)

Skilled nursing psychoactive treatments must be under the direction of a physician. Psychoactive treatments may only be provided by a physician or a registered nurse.

(3)

A registered nurse providing skilled nursing psychoactive treatments must have one of the following qualifications:

(A)

a master's degree in psychiatric or mental health nursing;

(B)

a bachelor's degree in nursing with one year of full-time experience in an active treatment unit in a mental health facility or outpatient clinic;

(C)

a diploma or associate degree with two years of full-time experience in an active treatment unit in a mental health facility or outpatient clinic; or

(D)

for a registered nurse for Medicare certified agencies, as allowed by the fiscal intermediary for Texas contracting with the United States Department of Health and Human Services (USDHHS) Health Care Financing Administration (HCFA).

(4)

An agency must have written documentation that a registered nurse providing skilled nursing psychoactive treatments is qualified under paragraph (3) of this subsection.

(5)

The initial health assessment of a client receiving skilled nursing psychoactive treatments must include:

(A)

mental status including psychological and behavioral status;

(B)

sensory and motor function;

(C)

cranial nerve function;

(D)

language function; and

(E)

any other criteria established by an agency's policy.

§97.407.Standards for Agencies Providing Home Intravenous Therapy.

An agency furnishing intravenous therapy directly or under arrangement must comply with the following standards of care.

(1)

A physician's order must be written specifically for intravenous therapy.

(2)

Intravenous therapy must be provided by a licensed nurse.

(3)

To insure that prescribed care is administered safely, a licensed nurse must have the knowledge and documented competency to interpret and implement the written order.

(4)

Written policies and procedures regarding the agency's provision of intravenous therapy must include, but are not limited to, addressing initiation, medication administration, monitoring, and discontinuation. Responsibilities of the licensed nurse must be clearly delineated in written policies and procedures.

(5)

A registered nurse must be available 24 hours per day.

(6)

The client and care giver must be assessed for the ability to safely administer the prescribed intravenous therapy as per agency written criteria.

(7)

If the client or care giver is willing and able to safely administer the prescribed intravenous therapy, the agency must offer to teach the client or care giver such administration. The teaching process is based on the client and care giver needs and may include written instructions, verbal explanations, demonstrations, evaluation and documentation of competency, proficiency in performing therapy, scope of physical activities, and safe disposal of equipment.

(8)

Actions must be implemented prior to and during all intravenous therapy to minimize the risk of anaphylaxis or other adverse reactions as stated in the agency's written policy.

(9)

An ongoing assessment of client and care giver compliance in performing therapy related procedures must be done at periodic intervals.

(10)

Care coordination must be provided in order to assure continuity of care.

(11)

The client and care giver must be provided with 24-hour access to appropriate health care professionals employed by or having a contract with the agency.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102159

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


Subchapter E. SURVEYS

40 TAC §97.501, §97.502

The new sections are proposed under the Health and Safety Code, Chapter 142, which provides the department with the authority to adopt rules for the licensing and regulation of home and community support services agencies.

The new sections implement the Health and Safety Code, Chapter 142.001-142.030.

§97.501.Survey Procedures.

(a)

An on-site survey will determine if the requirements of the statute and the rules are being met.

(1)

The Texas Department of Human Services (DHS) or its authorized representative(s) (surveyor) may enter the premises of a license applicant or license holder at reasonable times during business hours to conduct an on-site survey incidental to the issuance of a license, and at other times as it considers necessary to ensure compliance with the statute or the rules adopted under the statute, an order of the commissioner of human services (commissioner) or the commissioner's designee, a court order granting injunctive relief, or other enforcement action. A standard-by-standard evaluation is required before the first renewal license is issued unless waived in accordance with §97.13(b)(8) of this title (relating to Change of Ownership).

(2)

At the discretion of DHS, an on-site survey may be conducted for renewal of a license or issuance of a branch office or alternate delivery site license.

(3)

If there is a question relating to the accuracy of an agency's financial records relating to the operation of the agency or the agency's financial ability to carry out its functions, DHS or its designee may conduct an extensive review of the records. Any financial review by DHS will be conducted by an individual who has the financial qualifications to review such records.

(4)

The person in charge of the agency must be present at the time of a survey by DHS. For the purposes of this section, the person in charge of the agency is:

(A)

the administrator or designated alternate; or

(B)

the supervising nurse or designated alternate.

(5)

DHS or a representative of DHS is entitled to access to all books, records, or other documents maintained by or on behalf of the agency to the extent necessary to ensure compliance with the statute, this chapter, an order of the commissioner, a court order granting injunctive relief, or other enforcement action. Failure to grant access will result in immediate enforcement action. DHS will maintain the confidentiality of agency records as applicable under federal or state law. Ensuring compliance includes permitting photocopying by a DHS surveyor or providing photocopies to a DHS surveyor of any records or other information by or on behalf of DHS as necessary to determine or verify compliance with the statute or this chapter. Copies of clinical records supplied by the agency to DHS must be certified copies and must include a complete copy of all records requested by DHS.

(6)

By applying for or holding a license, the agency consents to entry and survey of the agency by DHS or a representative of DHS in accordance with the statute and this chapter.

(b)

Except for the initial survey, a survey conducted by DHS will be unannounced.

(c)

Except for the investigation of complaints, an agency licensed by DHS is not subject to additional surveys relating to home health, hospice, or personal assistance services while the agency maintains deemed accreditation status for the applicable services from the Joint Commission on Accreditation of Healthcare Organizations, the Community Health Accreditation Program. An initial survey after issuance of an initial license will be done by DHS:

(1)

if the agency is not yet accredited; or

(2)

unless waived under §97.13(b)(8) of this title (relating to Change of Ownership).

(d)

A DHS representative will hold a conference with the person in charge of the agency before beginning the on-site survey to explain the nature and scope of the survey. When the survey is completed, the DHS representative will hold an exit conference with the person in charge of the agency and will identify any records that were duplicated. Any records that are removed from an agency will be removed only with the consent of the agency.

(e)

A DHS representative will fully inform the person in charge of the agency of the preliminary findings of the survey and will give the person a reasonable opportunity to submit additional facts or other information to DHS's authorized representative in response to those findings. The response will be made a part of the record of survey for all purposes and must be received by DHS within ten calendar days of receipt of the preliminary findings of the survey by the agency.

(f)

After a survey of an agency, DHS will provide the chief executive officer of the agency:

(1)

specific and timely written notice of the findings of the survey including:

(A)

the specific nature of the survey;

(B)

any alleged violations of a specific statute or rule;

(C)

specific nature of any finding regarding an alleged violation or deficiency;

(D)

if a deficiency is alleged, the severity of the deficiency; and

(E)

if there are no deficiencies found, a statement indicating this fact;

(2)

information on the identity, including the signature, of each department representative conducting, reviewing, or approving the results of the survey and the date on which the department representative acted on the matter; and

(3)

if requested by the agency, copies of all documents relating to the survey maintained by the department or provided by the department to any other state or federal agency that are not confidential under state law.

(g)

The surveyor will:

(1)

conduct a survey for all categories of services authorized under the license;

(2)

conduct a minimum of three home visits unless the agency has only three clients;

(3)

review a minimum of ten client records unless the agency has had less than ten clients; such review must include a sample of pediatric clients if pediatric clients are served by the agency;

(4)

obtain a client's signature consenting to the home visit. A client may refuse a home visit without effect on the level and nature of care or benefit to the client;

(5)

prepare a statement of deficiencies, if any;

(6)

obtain a plan of correction for deficiencies which is provided by the agency either on-site or within ten calendar days of the agency's receipt of the statement of deficiencies and which indicates the date(s) by which correction(s) will be made;

(7)

obtain the signature of the person in charge of the agency acknowledging the receipt of the statement of deficiencies and plan of correction form. The person's signature does not indicate the person's agreement with deficiencies stated on the form;

(8)

obtain within ten calendar days of the survey written comments, if any, by the person in charge of the agency. Additional facts, written comments or other information provided by the agency in response to the findings will be made a part of the record of the survey for all purposes; and

(9)

inform person in charge of the agency of the agency's right of reconsideration of any deficiency(ies) cited and of the procedures for requesting a reconsideration. A reconsideration requested by an agency does not excuse the agency from submitting a plan of correction required in subsection (h)(1) of this section.

(h)

The agency must:

(1)

submit an acceptable written plan of correction for each deficiency no later than ten days from its receipt of a statement of deficiencies. A plan of correction date must not exceed 45 days from the date the deficiency was cited; and

(2)

correct each deficiency no later than the plan of correction date for that deficiency. Failure of an agency to correct each deficiency by the plan of correction date may result in enforcement action in accordance with Subchapter F of this chapter (relating to Enforcement).

(i)

If Medicare certification is denied by the Health Care Financing Administration (HCFA) or the agency withdraws from the Medicare program, the agency may only operate under the category remaining on the current license. The effective date of the change will be the date indicated on the final termination letter issued to the agency by HCFA. This change does not preclude DHS from taking enforcement action, if appropriate, under Subchapter F of this chapter (relating to Enforcement).

(j)

If deficiencies are cited and the plan of correction is not acceptable, DHS will notify the agency in writing and request that the plan of correction be resubmitted no later than 30 calendar days of the agency's receipt of DHS's written notice. Upon resubmission of an acceptable plan of correction, DHS will send written notice to the agency acknowledging same.

(k)

DHS will verify the correction of deficiencies by mail or by an on-site survey within 90 days of DHS's receipt of an acceptable plan of correction.

(l)

Acceptance of a plan of correction does not preclude DHS from taking enforcement action as appropriate under Subchapter F of this chapter (relating to Enforcement).

(m)

Except as provided by Health and Safety Code, §142.009(h), (i), and (l) an on-site survey will be conducted within 18 months after a survey for an initial license. After that time, an on-site survey will be conducted at least every 36 months.

(n)

If a person is renewing or applying for a license to provide more than one category of services under the statute or for a branch office or alternate delivery site license, the required surveys for each of the services or location(s) the license holder or applicant seeks to provide will be completed during the same survey visit.

§97.502.Complaint Investigation.

(a)

An agency must provide to each person who receives home health, hospice, or personal assistance services a written statement that informs the recipient that a complaint against the agency may be directed to the Texas Department of Human Services (DHS). The statement must be provided at the time of admission and must direct the recipient to register complaints with the Director of the Home and Community Support Services Program, Texas Department of Human Services (DHS), P.O. Box 149030, Austin, Texas 78714-9030, toll free 1-800-228-1570.

(b)

A complaint containing allegations that are a violation of the statute or this chapter will be investigated by DHS.

(c)

A complaint containing allegations that are not a violation of the statute or this chapter will not be investigated by DHS but will be referred to law enforcement agencies or other agencies, as appropriate.

(d)

DHS will inform in writing a complainant who identifies himself by name and address of the following information:

(1)

the receipt of the complaint;

(2)

whether the complainant's allegations allege potential violations of the statute or this chapter warranting an investigation;

(3)

whether the complaint will be investigated by DHS;

(4)

whether and to whom the complaint will be referred; and

(5)

the findings of the complaint investigation.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102160

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


Subchapter F. ENFORCEMENT

40 TAC §§97.601 - 97.604

The new sections are proposed under the Health and Safety Code, Chapter 142, which provides the department with the authority to adopt rules for the licensing and regulation of home and community support services agencies.

The new sections implement the Health and Safety Code, Chapter 142.001-142.030.

§97.601.License Denial, Suspension or Revocation.

(a)

The Texas Department of Human Services (DHS) may deny, suspend, suspend on an emergency basis, or revoke a license issued to an applicant or agency if the applicant or agency:

(1)

fails to comply with any provision of the statute;

(2)

fails to comply with any provision of this chapter;

(3)

has a provider agreement under the Social Security Act, Title XVIII, which has been terminated by the certifying body, Health Care Financing Administration, or if the agency withdraws its certification or its request for certification. An agency providing licensed and certified home health services that submits a request for a hearing as provided by this section is governed by the requirements of the statute and the rules relating to an agency providing licensed only home health services until suspension or revocation is finally determined by DHS or, if the license is suspended or revoked, until the last day for seeking review of the DHS order or a later date fixed by order of the reviewing court;

(4)

commits fraud, misrepresentation, or concealment of a material fact on any documents required to be submitted to DHS or required to be maintained by the agency pursuant to this chapter;

(5)

has aided, abetted, or permitted the commission of an illegal act;

(6)

fails to provide the required application or renewal information;

(7)

fails to comply with an order of the commissioner of human services or another enforcement procedure under the statute;

(8)

discloses action as described in §97.11(g)(3)(R) and (S) of this title (relating to Application and Issuance of Initial License) or §97.12(b)(2)(A) of this title (relating to Issuance and Renewal of License);

(9)

knowingly employs as the agency administrator or chief financial officer, an individual who was convicted of a felony or misdemeanor listed in subsection (b) of this section.

(b)

DHS may suspend or revoke an existing valid license or disqualify a person from receiving a license because of a person's conviction of a felony or misdemeanor if the crime directly relates to the duties and responsibilities of a licensed agency.

(1)

In determining whether a criminal conviction directly relates, DHS will consider the provisions of Texas Civil Statutes, Article 6252-13c.

(2)

The following felonies and misdemeanors directly relate because these criminal offenses indicate an inability or a tendency for the person to be unable to own or operate an agency. These offenses also relate to the holding of a home health medication aide permit or an entity approved under Subchapter H of this chapter (relating to Home Health Medication Aides), to conduct a home health medication aide training program:

(A)

a misdemeanor violation of the statute;

(B)

a conviction relating to deceptive business practices;

(C)

a misdemeanor or felony offense involving moral turpitude;

(D)

the misdemeanor of practicing any health-related profession without a required license;

(E)

a conviction under any federal or state law relating to drugs, dangerous drugs or controlled substances;

(F)

an offense under the Texas Penal Code involving a client or client of a health care facility or agency;

(G)

Texas Penal Code, Chapter 19 concerning criminal homicide;

(H)

Texas Penal Code, Chapter 20 concerning kidnapping and false imprisonment;

(I)

Texas Penal Code, §21.11 concerning indecency with a child;

(J)

Texas Penal Code, §22.011 concerning sexual assault;

(K)

Texas Penal Code, §22.02 concerning aggravated assault;

(L)

Texas Penal Code, §22.04 concerning injury to a child, elderly individual, or disabled individual;

(M)

Texas Penal Code, §22.041 concerning abandoning or endangering child;

(N)

Texas Penal Code, §22.08 concerning aiding suicide;

(O)

Texas Penal Code, §25.031 concerning agreement to abduct from custody;

(P)

Texas Penal Code, §25.08 concerning sale or purchase of a child;

(Q)

Texas Penal Code, §28.02 concerning arson;

(R)

Texas Penal Code, §29.02 concerning robbery;

(S)

Texas Penal Code, §29.03 concerning aggravated robbery;

(T)

a misdemeanor or felony offense under the Texas Penal Code, as follows:

(i)

Title 5, concerning offenses against the person;

(ii)

Title 7, concerning offenses against property;

(iii)

Title 9, concerning offenses against public order and decency;

(iv)

Title 10, concerning offenses against public health, safety, and morals; and

(v)

Title 4, concerning offenses of attempting or conspiring to commit any of the offenses in subparagraphs (A)-(T) of this paragraph; and

(vi)

other misdemeanors and felonies which indicate an inability or tendency for the person to be unable to own or operate an agency, hold a permit, or receive program approval under Subchapter H of this chapter (relating to Home Health Medication Aides), if action by DHS will promote the intent of the statute, this chapter, or Texas Civil Statutes, Article 6252-13c.

(3)

Upon a licensee's felony conviction, felony probation revocation, revocation of parole, or revocation of mandatory supervision, the license will be revoked.

(c)

Before the institution of proceedings to revoke or suspend a license or deny an application for the renewal of a license, DHS will give the license holder:

(1)

notice by personal service or by registered or certified mail of the facts or conduct alleged to warrant the proposed action; and

(2)

an opportunity to show compliance with all requirements of law for the retention of the license by sending the director of DHS's Long Term Care-Regulatory a written request for an informal reconsideration. The request must:

(A)

be postmarked within 10 days of the date of DHS's notice and be received in the state office of the director of DHS's Long Term Care- Regulatory within 10 days of the date of the postmark; and

(B)

contain specific documentation refuting DHS's allegations.

(d)

If the agency requests an informal reconsideration under subsection (c)(2) of this subsection, DHS's review will be limited to a review of documentation submitted by the license holder and information DHS used as the basis for its proposed action and will not be conducted as an adversary hearing. DHS will give the license holder a written affirmation or a reversal of the proposed action, as appropriate.

(e)

If DHS proposes to deny, suspend, or revoke a license, DHS will notify the agency by certified mail, return receipt requested, or personal delivery of the reasons for the proposed action and offer the agency an opportunity for a hearing. If a notice served by mail is returned undeliverable or DHS is unable to execute personal delivery of the notice, DHS will publish the notice in a newspaper of general circulation serving the county in which the agency is located based upon the last address provided by the agency. Publication of the notice will be for seven consecutive calendar days. An agency which fails to claim a notice sent by certified mail or refuses to accept the notice does not make the notice null and void.

(1)

The agency must request a hearing within 15 calendar days of receipt of the notice. The request must be in accordance with Chapter 79, Subchapter Q of this title (relating to Formal Hearings). Receipt of the notice is presumed to occur on the tenth day after the notice is mailed to the last address known to DHS unless another date is reflected on a United States Postal Service return receipt.

(2)

A hearing will be conducted pursuant to the Administrative Procedure Act, Texas Government Code, Chapter 2001, and DHS's formal hearing procedures in Chapter 79, Subchapter Q of this title (relating to Formal Hearings).

(3)

If the agency does not request a hearing in writing within 15 calendar days of receipt of the notice, the agency is deemed to have waived the opportunity for a hearing and the proposed action will be taken.

(4)

If the agency fails to appear or be represented at the scheduled hearing, the agency has waived the right to a hearing and the proposed action will be taken.

(5)

The denial, suspension, or revocation of a license will take effect when the deadline for appeal of the denial, suspension, or revocation passes, unless the agency appeals the enforcement action. If the agency appeals the enforcement action, the status of the license holder is preserved until final disposition of the contested matter.

(f)

DHS may suspend or revoke a license to be effective immediately when the health and safety of persons are threatened. DHS will immediately give the chief executive officer of the agency adequate notice of the action taken, the legal grounds for the action, and the procedure governing appeal of the action. DHS will also notify the agency of the emergency action including the legal grounds for the action and the procedure governing appeal of the action by certified mail, return receipt requested, or personal delivery of the notice and of the date of a hearing, which will be not later than seven calendar days after the effective date of the suspension or revocation. The effective date of the emergency action will be stated in the notice. The hearing will be conducted pursuant to the Administrative Procedure Act, Texas Government Code, Chapter 2001, and DHS's formal hearing procedures in Chapter 79, Subchapter Q of this title (relating to Formal Hearings).

(g)

If an agency has had enforcement action taken by DHS against the agency, the agency, its owner(s), or its affiliate(s) may not apply for an agency license or make any requests to change categories of license for one year following the effective date of the enforcement action. For purposes of this paragraph only, the term "enforcement action" means license revocation, suspension, emergency suspension, or denial or injunctive action but does not include administrative penalties or civil penalties. If DHS prevails in one enforcement action, such as an injunctive action, against the agency but also proceeds with another enforcement action, such as a revocation, based on some or all of the same violations, but DHS does not prevail in the second enforcement action (the agency prevails), the prohibition in this paragraph does not apply.

(h)

If DHS suspends a license, the suspension will remain in effect until DHS determines that the reason for suspension no longer exists. An authorized representative of DHS will conduct a survey of the agency prior to making a determination.

(1)

During the time of suspension, the suspended license holder must return the license to DHS.

(2)

If a suspension overlaps a renewal date, the suspended license holder must comply with the renewal procedures in this chapter; however, DHS may not renew the license until DHS determines that the reason for suspension no longer exists.

(3)

If suspension is for more than one year, the suspended license holder may apply to DHS for cancellation of the suspension only after one year following the initial date of the suspension.

(i)

If DHS revokes or does not renew a license and the one-year period described in subsection (h)(3) of this section has passed, a person may reapply for a license by complying with the requirements and procedures in this chapter at the time of reapplication. DHS may refuse to issue a license if the reason for revocation or nonrenewal continues to exist.

(j)

Upon revocation or nonrenewal, a license holder must return the license to DHS.

§97.602.Administrative Penalties.

(a)

General. The Texas Department of Human Services (DHS) may assess an administrative penalty against a person who violates the statute or this chapter. A person under this section includes a licensed agency.

(b)

Assessment of a penalty.

(1)

Notwithstanding any other provision of the statute, DHS may not assess an administrative penalty against an agency:

(A)

that provides only long-term care Medicaid waiver services that are publicly funded and is certified and monitored by a state agency that has developed standards that ensure the health and safety of service recipients; or

(B)

that provides home health, hospice, or personal assistance services only to persons enrolled in a program that is funded in whole or in part by the Texas Department of Mental Health and Mental Retardation (TXMHMR) and is monitored by the TXMHMR or its designated local authority in accordance with standards set by the TXMHMR.

(2)

The assessment of an administrative penalty will be in accordance with the schedule of appropriate and graduated penalties described in subsection (d) of this section. The schedule of appropriate and graduated penalties for each violation is based on the following criteria:

(A)

the seriousness of the violation, including the nature, circumstances, extent, and gravity of the violation, and the hazard of the violation to the health or safety of clients;

(B)

the history of previous violations by a person or a controlling person with respect to that person;

(C)

whether the affected home and community support services agency had identified the violation as part of its internal quality assurance process and had made appropriate progress on correction. For purposes of this subparagraph, appropriate progress is defined as making a good faith, substantial effort to correct the violation in a timely manner;

(D)

the amount necessary to deter future violations;

(E)

efforts made to correct the violation; and

(F)

any others matters that justice may require.

(3)

In determining which violation(s) warrants a penalty(ies), DHS will consider:

(A)

the seriousness of the violation(s), including the nature, circumstances, extent, and gravity of the violation(s), and the hazard of the violation(s) to the health or safety of a client; and

(B)

whether the affected agency had identified the violation(s) as part of its internal quality assurance process and had made appropriate progress on correction.

(4)

An administrative penalty for a subsequent occurrence may only be assessed when the subsequent occurrence occurs within three years from the date the agency first receives oral or written notice of the first violation.

(5)

The assessment of an administrative penalty does not preclude DHS from suspending, revoking, or denying a license in accordance with §97.601 of this title (relating to License Denial, Suspension or Revocation).

(c)

Correction period.

(1)

Following the first day of a violation, DHS will give an agency a reasonable period of time to correct the violation. The period of time must be reflected in and implemented through an accepted plan of correction. A reasonable period of time for purposes of this paragraph will be as follows.

(A)

For a violation that results in serious harm to or death of a client, constitutes an actual serious threat to the health or safety of a client, or substantially limits the agency's capacity to provide care, the violation must be corrected immediately or no later than seven calendar days from the first time the agency is informed (orally or in writing) by DHS staff of the violation. This is a severity level II violation.

(B)

For a violation that has or had minor or no health or safety significance, the violation must be corrected within 20 calendar days from receipt of the written notice of the violation (statement of deficiencies). This is a severity level I violation.

(C)

An agency may request an extension in writing. An agency may receive an extension upon DHS's approval. An extension is only appropriate if the agency has made a good faith effort to correct the violation within the required time period but has not been able to correct due to circumstances beyond their control and if there is no serious harm or threat to clients.

(2)

If an agency corrects the violation within the time periods described in paragraph (1) of this subsection, DHS may assess an administrative penalty only for one level II violation that occurred before the day on which the agency received written notice of the violation (statement of deficiencies). No administrative penalty would be assessed for a level I violation.

(3)

A penalty(ies) assessed under this section may be a severity level I penalty(ies) or a severity level II penalty(ies) or a combination of a severity level I penalty(ies) and severity level II penalty(ies). If an agency does not correct the violation within the time periods described in paragraph (1) of this subsection, DHS may assess an administrative penalty for:

(A)

one violation that occurred before the day on which the agency received written notice of the violation (statement of deficiencies); and

(B)

for each day of the violation during the correction period and after the time period for correction has ended.

(d)

Schedule of penalties.

(1)

Minimum and maximum amount. An administrative penalty may not be less than $100 or more than $1,000 for each violation.

(2)

Subject matter considered. If two or more of the rules listed in paragraphs (3) and (4) of this subsection relate to the same or similar subject matter, only one administrative penalty may be assessed at the higher severity level violation.

(3)

Severity level I. A severity level I violation is a violation that has or has had minor or no client health or safety significance.

(A)

The penalty for a severity level I violation will be assessed only if the violation is of a continuing nature or the violation was not corrected in accordance with the accepted plan of correction. DHS is not required to provide the agency an opportunity to correct subsequent violations under this section.

(B)

The penalty for a severity level I violation is $100-$250.

(C)

A violation of each of the rules listed in the following table may warrant a severity level I administrative penalty.

Figure: 40 TAC §97.602(d)(3)(C)

(4)

Severity level II.

(A)

The penalty for a severity level II violation will be assessed according to following schedule:

(i)

for a violation that results in serious harm to or death of a client, the penalty will be $1,000;

(ii)

for a violation that constitutes an actual serious threat to the health or safety of a client, the penalty will be $500 to $1,000; or

(iii)

for a violation that substantially limits the agency's capacity to provide care, the penalty will be $500 to $750.

(B)

DHS may assess a separate level II administrative penalty for a violation of each of the rules listed in the following table.

Figure 40 TAC §97.602(d)(4)(B)

(e)

Notice of violation. After investigation of a possible violation and the facts surrounding that possible violation and after the agency's receipt of the statement of deficiencies, if DHS determines that a violation has occurred, DHS will give further written notice, via a notice of violation letter, to the person alleged to have committed the violation.

(1)

The notice will include:

(A)

a brief summary of the alleged violation(s);

(B)

a statement of the amount of the proposed penalty based on the factors listed in subsection (b) of this section; and

(C)

a statement of the person's right to a hearing on the occurrence of the violation(s), the amount of the penalty, or both the occurrence of the violation(s) and the amount of the penalty.

(2)

Not later than the 20th calendar day after the date on which the notice is received, the person notified may accept the determination of DHS made under this section, including the proposed penalty, or may make a written request for a hearing on that determination. A person's acceptance of DHS's determination means that the person has sent and DHS has received a written acceptance notice accompanied by remittance of the proposed penalty.

(3)

If the person notified of the violation accepts the determination of DHS or if the person fails to respond in a timely manner to the notice, the commissioner or the commissioner's designee will issue an order approving the determination and ordering that the person pay the proposed penalty.

(4)

If the person requests a hearing, procedures will be in accordance with the statute, §§142.0172-142.0173 and DHS's formal hearing procedures in Chapter 79, Subchapter Q of this title (relating to Formal Hearings).

§97.603.Court Action.

(a)

If a person operates an agency without a license issued under the Act, the person is liable for a civil penalty of not less than $1,000 or more than $2,500 for each day of violation.

(b)

If a person violates the licensing requirements of the statute, the Texas Department of Human Services may petition the district court to restrain the person from continuing the violation.

§97.604.Surrender or Expiration of License.

(a)

After a survey in which deficiencies were cited by the surveyor, an agency may surrender its license before expiration or allow its license to expire in lieu of the Texas Department of Human Services (DHS) proceeding with enforcement action.

(b)

An agency may surrender before the expiration date by returning its original license to DHS.

(c)

If an agency surrenders or allows expiration of the license, the agency, its owner(s), and its affiliate(s) may not reapply for a license for six months from the date of the surrender or expiration.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102161

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


Subchapter G. HOME HEALTH AIDES

40 TAC §97.701

The new section is proposed under the Health and Safety Code, Chapter 142, which provides the department with the authority to adopt rules for the licensing and regulation of home and community support services agencies.

The new section implements the Health and Safety Code, Chapter 142.001-142.030.

§97.701.Home Health Aides.

(a)

A home health aide may be used by an agency providing licensed home health services if the aide meets one of the following requirements:

(1)

a minimum of one year full-time experience in direct client care in an institutional setting (hospital or nursing facility);

(2)

one year full-time experience within the last five years in direct client care in an agency setting;

(3)

satisfactorily completed a training and competency evaluation program which complies with the requirements of this section;

(4)

satisfactorily completed a competency evaluation program which complies with the requirements of this section;

(5)

submitted to the agency documentation from the director of programs or the dean of a school of nursing that states that the individual is a nursing student who has demonstrated competency in providing basic nursing skills in accordance with the school's curriculum; or

(6)

be on the Texas Department of Human Services' (DHS's) nurse aide registry with no finding against the aide relating to client abuse or neglect or misappropriation of client property.

(b)

Tasks to be performed by a home health aide must be assigned by and performed under the supervision of a registered nurse who must be responsible for the client care provided by a home health aide.

(c)

A home health aide may perform those tasks that are delegated and supervised by a registered nurse in accordance with §97.298 of this title (relating to Delegation of Selected Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel).

(d)

The training portion of a training and competency evaluation program for home health aides must be conducted by or under the general supervision of a registered nurse who possesses a minimum of two years of nursing experience, at least one year of which must be in the provision of home health care. The training program may contain other aspects of learning, but must contain the following:

(1)

a minimum of 75 hours as follows:

(A)

an appropriate number of hours of classroom instruction; and

(B)

a minimum of 16 hours of clinical experience which will include in-home training and must be conducted in a home, a hospital, a nursing home, or a laboratory;

(2)

completion of at least 16 hours of classroom training before a home health aide begins clinical experience working directly with clients under the supervision of qualified instructors;

(3)

if licensed vocational nurse instructors are used for the training portion of the program, the following qualifications and supervisory requirements apply:

(A)

a licensed vocational nurse may provide the home health aide classroom training under the supervision of a registered nurse who has two years of nursing experience, at least one year of which must be in the provision of home health care;

(B)

licensed vocational nurses, as well as registered nurses, may supervise home health aide candidates in the course of the clinical experience; and

(C)

a registered nurse must maintain overall responsibility for the training and supervision of all home health aide training students; and

(4)

an assessment that the student knows how to read and write English and carry out directions.

(e)

The classroom instruction and clinical experience content of the training portion of a training and competency evaluation program must include, but is not limited to:

(1)

communications skills;

(2)

observation, reporting, and documentation of a client's status and the care or service furnished;

(3)

reading and recording temperature, pulse, and respiration;

(4)

basic infection control procedures and instruction on universal precautions;

(5)

basic elements of body functioning and changes in body function that must be reported to an aide's supervisor;

(6)

maintenance of a clean, safe, and healthy environment;

(7)

recognizing emergencies and knowledge of emergency procedures;

(8)

the physical, emotional, and developmental needs of and ways to work with the populations served by the agency including the need for respect for the client and his or her privacy and property;

(9)

appropriate and safe techniques in personal hygiene and grooming that include:

(A)

bed bath;

(B)

sponge, tub, or shower bath;

(C)

shampoo, sink, tub, or bed;

(D)

nail and skin care;

(E)

oral hygiene; and

(F)

toileting and elimination;

(10)

safe transfer techniques and ambulation;

(11)

normal range of motion and positioning;

(12)

adequate nutrition and fluid intake;

(13)

any other task that the agency may choose to have the home health aide perform in accordance with §97.298 of this title (relating to Delegation of Selected Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel); and

(14)

the rights of the elderly.

(f)

This section addresses the requirements for the competency evaluation program or the competency evaluation portion of a training and competency evaluation program.

(1)

The competency evaluation must be performed by a registered nurse.

(2)

The competency evaluation must address each of the subjects listed in subsection (e)(2)-(13) of this section.

(3)

Each of the areas described in subsection (e)(3) and (9)-(11) of this section must be evaluated by observation of the home health aide's performance of the task with a client or person.

(4)

Each of the areas described in subsection (e)(2), (4)-(8), (12), and (13) of this section may be evaluated through written examination, oral examination, or by observation of a home health aide with a client.

(5)

A home health aide is not considered to have successfully completed a competency evaluation if the aide has an unsatisfactory rating in more than one of the areas described in subsection (e) (2)-(13) of this section.

(6)

If an aide receives an unsatisfactory rating, the aide must not perform that task without direct supervision by a registered nurse or licensed vocational nurse until the aide receives training in the task for which he or she was evaluated as unsatisfactory and successfully completes a subsequent competency evaluation with a satisfactory rating on the task.

(7)

If an individual fails to complete the competency evaluation satisfactorily, the individual must be advised of the areas in which he or she is inadequate.

(g)

If a person, who is not an agency licensed under this section, desires to implement a home health aide training and competency evaluation program or a competency evaluation program, the person must meet the requirements of this section in the same manner as set forth for an agency.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102162

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 438-3108


Part 5. TEXAS VETERANS LAND BOARD

Chapter 175. GENERAL RULES OF THE VETERANS LAND BOARD

40 TAC §§175.9, 175.12, 175.14 - 175.16, 175.19

The Veterans Land Board of the State of Texas (the "Board") proposes amendments to Title 40, Part 5, Chapter 175 of the Texas Administrative Code, §§175.9 (relating to "Death of a Purchaser"), 175.12 (relating to "Severances"), 175.14 (relating to "Mineral Leases"), 175.15 (relating to "Approval of Easements"), 175.16 (relating to "Payment in Full"), and 175.19 (relating to "Subdivision Loan Processing") of the General Rules of the Veterans Land Board. These amendments delete references to fee amounts in these sections, correct a prescribed form that references years beginning with "19__," correct some punctuation errors, and eliminate some procedures relating to appraisals of subdivisions. These amendments are being proposed concurrently with the proposed repeals of, and substitutions of new rules for, §175.17 (relating to "Fees and Deposits") of the General Rules of the Veterans Land Board and §177.9 (relating to "Fees, Expenses, and Interest") of the Veterans Housing Assistance Program.

The existing rules create fees that are charged by the Board. The amounts of these fees are found in several different rules. The proposed amendments delete the specific fee amounts from all rules. Concurrently published proposed repeals and substitutions for §175.17 of the General Rules of the Veterans Land Board and §177.9 of the rules for The Veterans Housing Assistance Program will specify fee amounts respectively for the Veterans Land Program (the "Program") and the Veterans Housing Assistance Program.

In addition, the rules proposed for amendment contains minor punctuation errors. The rules also quote required language that references years beginning with "19__." The proposed amendments correct the punctuation errors and change the reference to years beginning with "19__" to "20__."

Finally, §175.19 refers to a $25 fee for application documents that is no longer charged by the Board. The proposed amendment to§175.19 eliminates the fee and procedures associated with it.

The proposed amendments, if adopted, are a necessary first step to protecting the best interests of the Program by allowing the Board to list all fees in one rule for the Program and in one rule for the Veterans Housing Assistance Program.

Larry Soward, Chief Clerk of the General Land Office, has determined that for each year of the first five years the sections as amended are in effect, there will be no negative fiscal implications to state or local government as a result of enforcing or administering the sections. These sections, as amended, are a necessary preliminary step to permitting the Board to consolidate in one rule, for each of its loan programs, the specific amounts of all fees it charges.

Larry Soward, Chief Clerk of the General Land Office, has determined that for each year of the first five years the sections as proposed will be in effect, the public will benefit by being able to find all fees charged by the Board listed in one rule for each of its loan programs.

Mr. Soward has determined that the proposed amendments will have no effect on small businesses during each year of the first five years the sections are in effect.

Mr. Soward has also determined that during each year of the first five years the proposed amendments are in effect, there is no anticipated economic cost to any persons who are required to comply with the sections.

Comments may be submitted to Melinda Tracy, Legal Services, General Land Office of the State of Texas, 1700 N. Congress Avenue, Austin, Texas 78701.

The amendments to the sections are proposed under the Natural Resources Code, Title 7, Chapter 161, §§161.063, 161.069, and 161.070, which provides authorization for the Board to adopt rules for the Program which it considers necessary and advisable, and set fees

Natural Resources Code §161.069 is affected by this proposed action.

Natural Resources Code §161.070 is affected by this proposed action.

§175.9.Death of a Purchaser.

(a)

Upon the death of the purchaser, if the account is insured under the group life insurance plan, the board should be notified at once and furnished with a certified copy of the death certificate and a [ $80 ] deed fee, which is not paid under the group insurance plan.

(b)

If the account is not insured at the time of the purchaser's death, the board should be furnished:

(1)

certified copies of all probate proceedings, if any; or

(2)

an affidavit of heirship, if the purchaser dies intestate and no administration is necessary for the estate.

(c)

The person or persons acquiring the rights of the deceased purchaser should indicate to the board that they are willing to accept the obligations of the contract of sale and purchase.

(d)

Upon receipt of the items listed in subsections (a), (b), and (c) of this section, the records of the board will be changed to reflect the new ownership.

§175.12.Severances.

(a)

If a veteran wishes to have clear title to a portion of the land he is purchasing, he may obtain a severance deed from the board for that portion. To accomplish this the following steps should be taken:

(1)

A current ground survey of the portion to be severed must be made by a qualified surveyor. The survey requirements of §175.4 of this title (relating to Land Descriptions) must be met. The field notes and plat prepared from the ground survey must be submitted to the board.

(2)

Both the tract to be severed and the remaining tract must have access to a public road. If the severed tract includes all of the road frontage, a 60 foot access easement to the portion remaining under contract must be conveyed to the board.

(3)

Upon receipt of the field notes and plat, the board will have an appraisal made to determine the amount to be paid for the severed acreage. The veteran will be notified of the result of this appraisal. This amount, which will be applied against the principal of the veteran's account, should be submitted to the board, along with a [ $80 ]deed fee. The board will then issue a deed, conveying clear title to the severed portion.

(b)

The board will not issue severance deeds listing anyone besides the original veteran purchaser or the last approved assignee as the grantee.

(c)

All requests for severances will be subject to the approval of the chairman of the board.

(d)

The chairman of the board is authorized to enter into, and execute on behalf of the board, an agreement recognizing that an improvement, when constructed, shall not attach to and become a part of the realty for the duration of any obligation incurred by a purchaser in connection with the erection of such improvement.

§175.14.Mineral Leases.

(a)

When applicable, a veteran may execute mineral leases covering the land being purchased through the board. The following conditions must be met:

(1)

No oil and gas lease will be accepted unless the board's standard form is used. Copies of this form will be furnished upon request.

(2)

The lease must be approved by the chairman of the board.

(3)

Each lease must state the actual and true consideration to be paid.

(4)

At least 1/2 of all proceeds, including bonus, rentals and royalties received under the terms of such leases, shall be paid to the board and applied toward the principal balance of the account. If an account is delinquent, the board will require that additional payments of bonus, rental and royalty be paid until the delinquency is satisfied. Payments made in this manner will not relieve the veteran of his obligation to make the regular installment payments.

(5)

The lease term may not exceed 10 years, except when a lease is held in force by production. However, coal and lignite leases may be executed, with board approval, for terms up to 40 years.

(6)

No lease may contain a provision for an option, renewal or release for any term, nor may such provision be provided for by separate instrument.

(b)

Each executed mineral lease must be submitted to the board in duplicate. The approved original will be returned for recording with the county clerk. One half of the bonus payment should accompany the lease, along with a lease review fee [ service fee in the amount of $100 ]. If the account is delinquent, all of the bonus payment, or as much as may be required, should be sent to the board to satisfy the delinquency.

(c)

At least five acres around and including improvements on a tract must be excluded from all leases executed for iron ore, gravel, coal, or other substances, the mining or development of which tends to destroy the surface value of the land.

(d)

The veteran may lease the property for agricultural, hunting or grazing purposes or for other surface uses without obtaining the approval of the board. However, if the tract is forfeited the rights of the lessee are then terminated.

§175.15.Approval of Easements.

(a)

A contract holder may, with the approval of the board, grant easements or rights of way. These are of four general types:

(1)

A right of way granted to the state or county for roads, channels, etc. The forms to be used in granting such an easement may be obtained from the board or the State Highway Department of Highways and Public Transportation.

(2)

Utility easements for pipelines, electric lines, etc. The board requires use of its form when granting such an easement, except when an easement for a waterline is to be granted. In that case the FHA form may be used. If an FHA form is used, a course and distance description of the waterline must be attached.

(3)

Flowage easements granted in connection with dams and reservoir projects. The agency administering the project furnishes the forms for such easements. An elevation contour map of the acreage involved, together with an engineer flood data sheet, may be used in place of a course and distance description.

(4)

Easement for right of way purposes. The board does not require the use of a specified form for easements of this type. However, a form that may be used as a guide is available from the board.

(b)

If a VLB form is not used, the following paragraph must be inserted into the grant of easement. This paragraph more fully explains the conditions of ownership of the tract of land: "The land herein described is under Contract of Sale and Purchase to grantor herein who will receive a deed to said lands from the Veterans Land Board when all the terms of said contract have been complied with. Grantor executes this instrument with the approval of the Veterans Land Board in accordance with the regulations of said board, which approval is signified by the signature hereon of its chairman." A signature block must be provided at the conclusion of the instrument, as follows: Approved this __________ day of __________, 20__ [ 19__ ] Veterans Land Board of the State of Texas by: ___________________________Chairman, Veterans Land Board.

(c)

The contract holder must submit two original grants of easement to the board. These must be signed by the contract holder and acknowledged by a notary public.

(d)

A fee must [ of $40 per easement is to ]be paid to the board for review and approval of such easements. This fee is to be submitted to the board, along with the duplicate easement documents and any consideration paid, at the time the board's approval is requested.

(e)

The consideration paid for the easement must be stated clearly and accurately. Statements such as "ten dollars and other good and valuable consideration" are not acceptable.

(f)

All cash consideration paid for an easement must be submitted to the board. The board will distribute the consideration in light of the account's payment record, the amount of consideration and the effect on the value of the land. At least one-half of the consideration will be retained by the board and applied to the principal balance of the account.

(g)

Any payment made to compensate for temporary damage to the land, such as to growing crops or to plowed fields, should be paid directly to the contract holder. The amount of such payment and its purpose must be specifically stated in the grant of easement.

(h)

If payment is made for permanent damage to or depletion of the land (such as the cutting of timber), one half of that amount must be paid to the board. This amount is to be applied to the principal of the veteran's account.

(i)

If the easement is to be donated, the grant of easement should so state

§175.16.Payment in Full.

(a)

When an account is paid in full the board will draft a deed conveying the land to the original veteran-purchaser or the last approved assignee. If a deed is executed to someone other than the legal owner, the deed and the rights thereto shall inure to the benefit of the legal owner. A [ An $80 ] fee must be paid to the board for issuance of the deed.

(b)

The board will accept a cashier's check, certified check, personal check, money order or cash as final payment.

(c)

The board will furnish a final statement to the contract holder at any time upon request.

§175.19.Subdivision Loan Processing.

(a)

To qualify for subdivision loan processing a seller must:

(1)

have, or plan to have at least five tracts of land available for sale to veterans in the same subdivision or development;

(2)

agree to comply with all local ordinances and regulations regarding the subdivision or resubdivision of land; and

(3)

agree to provide the services and materials described in this rule to interested veterans in order to facilitate the board's processing of loans.

(b)

A written request for subdivision loan processing of an existing or proposed subdivision must be submitted to the board.

(c)

Those sellers who qualify for subdivision loan processing may request the board to perform a preliminary appraisal of the subdivision. This preliminary appraisal process will include:

(1)

Establishing high and low per acre values for the subdivision. The board will use these valuations in determining how much it will loan for the purchase of tracts in the subdivision.

(2)

Advising the seller, when appropriate, of the best subdivision plan, so as to maximize land values of the gross acreage for sale.

(3)

Discussing requirements for roads, easements, water sources and other factors affecting land values. Recommendations will be made if appropriate.

(d)

A [ The ] fee is charged for the preliminary subdivision appraisal [ is $2.00 per acre, calculated on gross acreage available in the subdivision. The minimum fee is $250 ].

(e)

After the preliminary appraisal has been completed and the seller indicates that tracts within a subdivision are ready for sale to veterans, the seller may make arrangements with the board for appraisals of specific tracts. The board will commit itself to a loan value based upon these appraisals even though a specific veteran purchaser has not yet been identified. To obtain these appraisals, the seller must:

(1)

Supply a ground survey of each tract of land by a registered surveyor.

(2)

Submit to the board a certified copy of a recorded subdivision plat, if the tracts are to be sold by lot and block numbers. This plat must contain evidence that it has been approved and accepted by the county commissioners.

(3)

Obtain a title insurance commitment for each tract;

(4)

Request a field appraisal of each tract by the board. A fee [ of $120 ]is charged in advance for each appraisal. This fee will be refunded to the seller if the tract is sold to a veteran through the Veterans Land Program; and

(5)

Furnish a recorded subdivision plat, if requested by the board.

(f)

Sellers may arrange to obtain application packets from the board. [ These packets will not have an application serial number or a 90 day void date on them and will be handled as follows: ]

[(1)

the application packet will be inactive until a veteran purchases it from the seller for $25 and that amount is received by the board, along with the veteran's name, address and phone number; ]

[(2)

the board will then assign a serial number and a 90 day void date to the application; ]

[(3)

the veteran and the seller may complete an application the same day it is sold to the veteran and mail the completed packet to the board at that time; ]

[(4)

the application becomes the property of the veteran when it is activated and it may be used for the purchase of any land that the veteran wishes to buy which qualifies for the veteran land program.]

(g)

Sellers using the subdivision loan processing system should help veterans complete all forms and documents required for processing and closing loans. Sellers will also be responsible for having veterans:

(1)

submit the correct amounts for down payments and fees required by the board; and

(2)

provide any missing documentation needed in order to qualify, process, or close a loan.

(h)

Completed application packets must be received by the board within 30 days of the date the application contract is signed.

(i)

Application packets are to be submitted by the seller and must include:

(1)

a copy of the recorded subdivision plat or other evidence of compliance with local regulations and ordinances; and

(2)

a title insurance commitment for the tract to be purchased.

(j)

Due to the nature and purpose of the subdivision loan processing program, it is the seller's responsibility to work with the veteran and the board to expedite the processing of the loan. For this reason it is suggested that the seller designate one individual to serve as a contact person with the board. This person should be familiar with the board's forms, rules, procedures, and any other requirements necessary for successful processing of the loan. In this regard it is also suggested that the contact person familiarize himself and maintain regular contacts with the board's field staff, county committees, local veterans' service officers, and the title company providing insurance.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102140

Larry R. Soward

Chief Clerk, General Land Office

Texas Veterans Land Board

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 305-9129


40 TAC §175.17

(Editor's note: The text of the following section proposed for repeal will not be published. The section may be examined in the offices of the Texas Veterans Land Board or in the Texas Register office, Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)

The Veterans Land Board of the State of Texas (the "Board") proposes to repeal and propose a new §175.17 (relating to Fees and Deposits) of the General Rules of the Veterans Land Board, Title 40, Part 5, Chapter 175 of the Texas Administrative Code.

This repeal and substitution is proposed concurrently with amendments to Title 40, Part 5, Chapter 175 of the Texas Administrative Code, §§175.9 (relating to Death of a Purchaser), 175.12 (relating to Severances), 175.14 (relating to Mineral Leases), 175.15 (relating to Approval of Easements), 175.16 (relating to Payment in Full), 175.19 (relating to Subdivision Loan Processing) and 177.9 (relating to Fees, Expenses, and Interest) of the General Rules of the Veterans Land Board. The foregoing amendments remove references to the amounts of all fees charged by the Board from all existing rules.

By repealing §175.17 and proposing a new rule in its place, the Board describes in a single rule all fees it charges in the Veterans Land Program. The proposed rule changes the existing fees as follows: (1) It authorizes the Board to adopt by resolution, from time-to-time, a schedule describing all services for which it charges a fee; (2) It authorizes the chairman or executive secretary of the Board to waive the collection of any fee, on a case by case basis, if it serves the best interests of the program; (3) It establishes maximum amounts for fees the Board can set by resolution. These maximum amounts are described in the rule. In order to set any fee in a greater amount, the Board must propose an amendment to the rule; and (4) It changes the appraisal fee from $120 to an amount not to exceed $250 and the reappraisal fee from $120 to an amount not to exceed $100. The service fee for contracts is changed from $70 to an amount not to exceed $75. The returned check fee is changed from $15 to $25. The $25 application fee; the $25 forfeited land bid fee; the $375 administrative cost and application processing fee; and the reinstatement fee are all eliminated. All other existing fees are limited to an amount not to exceed $75 each.

All of the proposed new rules, if adopted, protect the best interests of the Programs by allowing the Board to list all fees in one rule for each loan program and set the amount of individual fees, expenses, and interest rates by resolution. This allows the Board to operate the Program in a manner that is responsive to the needs of veterans as market conditions change over time.

Larry Soward, Chief Clerk of the General Land Office, has determined that for each year of the first five years the section as amended is in effect, there will be no overall negative fiscal implications to state or local government as a result of enforcing or administering the section. This section, as proposed, consolidate in one rule, for each of its loan programs, the specific amount of each fee the Board charges, or permits other parties to charge participants.

Larry Soward, Chief Clerk of the General Land Office, has determined that for each year of the first five years the section as proposed will be in effect, the public will benefit by being able to find all fees charged by the Board listed in one rule for each of its loan programs. Several fees have been eliminated and others reduced. The total fees charged by the Board during the course of originating a typical loan through the Veterans Land Program will decrease approximately $420.

Mr. Soward has determined that the proposed amendment will have no effect on small businesses during each year of the first five years the sections are in effect.

Mr. Soward has also determined that during each year of the first five years the proposed amendments are in effect, there is no anticipated economic cost to any persons who are required to comply with the sections.

Comments may be submitted to Melinda Tracy, Legal Services, General Land Office of the State of Texas, 1700 N. Congress Avenue, Austin, Texas 78701.

The repeal of this section is proposed under the Natural Resources Code, Title 7, Chapter 161, §§161.063, 161.069, and 161.070 which authorize the Board to set fees and adopt rules for the Programs which it considers necessary and advisable.

Natural Resources Code §§161.069 and 161.070 are affected by this proposed action.

§175.17.Fees and Deposits.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102144

Larry R. Soward

Chief Clerk, General Land Office

Texas Veterans Land Board

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 305-9129


40 TAC §175.17

The new section is proposed under the Natural Resources Code, Title 7, Chapter 161, §§161.063, 161.069, and 161.070 which authorize the Board to set fees and adopt rules for the Programs which it considers necessary and advisable.

Natural Resources Code §§161.069 and 161.070 are affected by this proposed action.

§175.17.Fees and Deposits.

(a)

Notwithstanding any other references to fees in this chapter to the contrary, the only fees collected by the board shall be those described in this section.

(1)

The board shall from time-to-time adopt by resolution a schedule describing the services for which it charges fees. The board's resolution adopting a schedule shall set the specific fee for each service described in the schedule, provided that no fee shall exceed the maximum amounts described in this section. The schedule will be made available to any person upon request and will be published on the board's Internet site.

(2)

If another law of the state requires the board to perform a service, the board shall collect the fee authorized by said law.

(3)

On a case-by-case basis, the chairman or the executive secretary may waive the collection of any fee described in this section if it serves the best interests of the program.

(b)

The board shall collect the following fees when they are applicable:

(1)

a fee not to exceed $250 for a regular (or first) appraisal of a tract of land;

(2)

a fee not to exceed $100 for the reappraisal of land previously appraised by the board for the same transaction;

(3)

a fee for a subdivision pre-appraisal and consultation fee -- $2 per acre, calculated on the gross acreage in the subdivision, with a minimum of $250;

(4)

a fee not to exceed $25 for a returned check (NSF);

(5)

The board shall collect a fee not to exceed $75 for the preparation, review, or approval of any document, including but not limited to the following:

(A)

contract of sale and purchase;

(B)

mineral lease or assignment of mineral lease;

(C)

easement, including but not limited to utility easements, access right of ways, and recreational;

(D)

transfer of contract and sale and purchase;

(E)

deed issued when a portion of a tract is severed prior to the full payment of its loan;

(6)

a fee for a deed issued when a loan is paid in full, not to exceed:

(A)

$75 if the contract incorporates this chapter by reference, or includes a general reference to the rules and/or regulations of the board; or

(B)

the amount of the fee that was in effect on the date the contract was executed if the contract contains no reference to the rules and/or regulations of the board.

(c)

No fee may be charged in connection with the program to a loan applicant by a third party that has not been approved by the board.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102143

Larry R. Soward

Chief Clerk, General Land Office

Texas Veterans Land Board

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 305-9129


Chapter 177. VETERANS HOUSING ASSISTANCE PROGRAM

40 TAC §177.9

(Editor's note: The text of the following section proposed for repeal will not be published. The section may be examined in the offices of the Texas Veterans Land Board or in the Texas Register office, Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)

The Veterans Land Board of the State of Texas (the "Board") proposes to repeal and propose a new §177.9 (relating to Fees, Expenses, and Interest) of the Veterans Housing Assistance Program, Title 40, Part 5, Chapter 177 of the Texas Administrative Code.

This repeal and substitution is proposed concurrently with amendments to Title 40, Part 5, Chapter 175 of the Texas Administrative Code, §§175.9 (relating to Death of a Purchaser), 175.12 (relating to Severances), 175.14 (relating to Mineral Leases), 175.15 (relating to Approval of Easements), 175.16 (relating to Payment in Full), 175.17 (relating to Fees and Deposits) and 175.19 (relating to Subdivision Loan Processing) and 177.9 (relating to Fees, Expenses, and Interest) of the General Rules of the Veterans Land Board. The foregoing amendments remove references to the amounts of all fees charged by the Board from all existing rules.

By repealing §177.9 and proposing a new rule in its place, the Board describes in a single rule all fees that may be charged by all parties participating in the Veterans Housing Assistance Program. The proposed rule makes the following changes: (1) It requires all fees and interest rates changed in connection with the Veterans Housing Assistance Program by any party to be submitted to the Board for approval. This includes fees charged to borrowers by the Board or by participating lending institutions and fees charged to participating lending institutions by the administrator; (2) It permits the Board to approve and set all fees by the adoption of resolutions from time-to-time; (3) It limits the amounts of fees, expenses, and interest rates charged by lending institution to those amounts collected by the institutions in the normal course of their residential mortgage lending businesses; and (4) The administrator shall incorporate in the Servicing Guide for the Veterans Housing Assistance Program provisions for the maximum amounts of fees, expenses and interest rates that participating lending institutions may charge.

All of the proposed new rules, if adopted, protect the best interests of the Programs by allowing the Board to list all fees in one rule for each loan program and set the amount of individual fees, expenses, and interest rates by resolution. This allows the Board to operate the Programs in a manner that is responsive to the needs of veterans as market conditions change over time.

Larry Soward, Chief Clerk of the General Land Office, has determined that for each year of the first five years the section as amended is in effect, there will be no overall negative fiscal implications to state or local government as a result of enforcing or administering the sections. This section, as proposed, consolidate in one rule, for each of its loan programs, the specific amount of each fee the Board charges, or permits other parties to charge participants.

Larry Soward, Chief Clerk of the General Land Office, has determined that for each year of the first five years the section as proposed will be in effect, the public will benefit by being able to find all fees charged by the Board listed in one rule for each of its loan programs.

Mr. Soward has determined that the proposed amendment will have no effect on small businesses during each year of the first five years the sections are in effect.

Mr. Soward has also determined that during each year of the first five years the proposed amendment is in effect, there is no anticipated economic cost to any persons who are required to comply with the sections.

Comments may be submitted to Melinda Tracy, Legal Services, General Land Office of the State of Texas, 1700 N. Congress Avenue, Austin, Texas 78701.

The repeal of this section is proposed under the Natural Resources Code, Title 7, §§162.003(a)(3) and (b), 162.011(e), and 162.013, which authorize the Board to set fees and adopt rules for the Programs which it considers necessary and advisable.

Natural Resources Code §§162.003(a)(3) and (b); 162.011(e); and 162.013 are affected by this proposed action.

§177.9.Fees, Expenses, and Interest

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102142

Larry R. Soward

Chief Clerk, General Land Office

Texas Veterans Land Board

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 305-9129


40 TAC §177.9

The proposed new section is proposed under the Natural Resources Code, Title 7, §§162.003(a)(3) and (b), 162.011(e), and 162.013, which authorize the Board to set fees and adopt rules for the Programs which it considers necessary and advisable.

Natural Resources Code §§162.003(a)(3) and (b); 162.011(e); and 162.013 are affected by this proposed action.

§177.9.Fees, Expenses, and Interest.

(a)

The board must approve all fees and interest rates charged in connection with the program, by any party. These include, but are not limited to:

(1)

All fees charged by any party to a veteran receiving a loan under this program must be approved by the board, including fees, expenses, and interest rates charged by the participating lending institution on its portion of the loan to the veteran. Fees and expenses approved by the board may be made a part of the veteran's loan installment payments.

(2)

All fees and expenses charged to a participating lending institution under this program by the administrator.

(b)

The board finds that it protects the best interests of the program if all fees, expenses, and interest rates are set by resolutions adopted by the board from time-to-time as it deems advisable.

(1)

Within a reasonable period of time, the board shall either approve or disapprove any proposed changes to any fees, expenses, and interest rates charged by a participating lending institution.

(2)

All fees, expenses, and interest rates shall be limited to the maximum extent practical to those that would be collected by the participating lending institution in the normal course of its residential mortgage lending business.

(3)

The administrator shall incorporate in the program and servicing guide (the "guide") for participating lending institutions provisions for the maximum that may be charged. In the alternative, the administrator shall incorporate in the guide the procedures for computing the maximum fees, expenses, and interest rates which participating lending institutions may charge veterans. The contracts between the board and the participating lending institutions shall incorporate the guide.

(4)

Violation by a participating lending institution of the board's requirements as to maximum fees, expenses, and interest rates may result in revocation of the board's approval of the lending institution as a participant in the program, or such other remedies as may be available to the board.

(c)

The board may require that the veteran make a down payment not to exceed 5.0% of the total purchase price of the home. This down payment shall be paid to the participating lending institution at closing. In the alternative, the board may require a down payment not to exceed 5.0% of the board's portion of the loan to be paid to the board. In this event, the veteran shall satisfy the participating lending institution's requirements as to down payment for the particular type of loan being made by the participating lending institution.

(d)

Principal and interest that becomes delinquent shall be subject to a penalty fixed by the board on its portion of the loan. The participating lending institution may set late payment penalties as permitted by law on its portion of the loan.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 16, 2001.

TRD-200102141

Larry R. Soward

Chief Clerk, General Land Office

Texas Veterans Land Board

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 305-9129


Part 17. STATE PENSION REVIEW BOARD

Chapter 604. HISTORICALLY UNDERUTILIZED BUSINESS PROGRAM

40 TAC §604.1

The State Pension Review Board (hereafter referred to as the Board) proposes new §604.1, concerning Historically Underutilized Businesses. The new rule will incorporate by reference the rules adopted by the General Services Commission (GSC) for historically underutilized businesses. The new rule conforms with Texas Government Code, §2161.003 which directed state agencies to adopt the GSC rules regarding historically underutilized businesses (HUB) as the agencies' own rules. The GSC rules appear in 1 Texas Administrative Code §§111.11-111.27. The Board's proposed rule adopts by reference GSC's rules.

The GSC rules being adopted by reference provide for a policy and a purpose for the rules, definitions applicable to the HUB rules, annual procurement HUB utilization goals, subcontracting requirements, agency planning responsibilities, state agency reporting requirements, a HUB certification process, protests from denial of HUB applications, a HUB recertification process, revocation provisions, certification and compliance reviews, compilation of a HUB directory, HUB graduation procedures, review and revisions of GSC's HUB program, a memorandum of understanding between GSC and the Texas Department of Economic Development concerning technical assistance and budgeting for the HUB program, HUB Coordinator responsibilities, HUB forum programs for state agencies, and a mentor-protégé program.

Rita Horwitz, Executive Director, has determined that for each year of the first five years the proposed sections will be in effect, there will be no fiscal impact to state and local governments as a result of the enforcement or administration of the rule. There will be no measurable effect on local employment or the local economy as a result of the proposal.

Ms. Horwitz, has determined that for each year of the first five years the sections are in effect, the public benefits anticipated as a result of the proposed section will be a more uniform and consistent approach for procuring goods and services from HUB vendors. There is no anticipated economic cost to persons who are required to comply with the rule. There is no anticipated difference in cost of compliance between micro, small, and large businesses and no anticipated economic cost for these entities. State agencies are required to comply with the rules for historically underutilized businesses as adopted by the GSC.

Comments may be submitted to Rita Horwitz, Executive Director, The State Pension Review Board, P.O. Box 13498, Austin, Texas 78711-3498. Adoption of proposed rule will be a minimum of 30 days after publication.

The new section is proposed under the Texas Administrative Code, Title 40, Part 17, §604.1 and §2161.003 of the Government Code requires that the Board adopt the GSC rules for Historically Underutilized Businesses. Section 802.201 of the Government Code provides that the Board shall adopt rules for the conduct of business.

The following articles are affected by this proposal: Government Code, §2161.003, Historically Underutilized Businesses. The Board adopts by reference the rules promulgated by the GSC regarding historically underutilized businesses, which are set forth in 1 TAC §§111.11-111.27.

§604.1.Historically Underutilized Businesses.

The Board adopts by reference the rules promulgated by the General Services Commission (GSC) regarding historically underutilized businesses, which are set forth in 1 TAC §§111.11-111.27, as amended. A copy of the GSC rules may be obtained by writing to: Rita Horwitz, Executive Director, State Pension Review Board, P.O. Box 13498, Austin, Texas 78711-3498 or by accessing the Web site of the Secretary of State, at www.sos.state.tx.us/tac/.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State, on April 9, 2001.

TRD-200102032

Lynda Baker

Administrative Assistant

State Pension Review Board

Earliest possible date of adoption: May 27, 2001

For further information, please call: (512) 463-1736